Flinders Deaths

[Guest]

I just read this in Briefings, I thought the whole thing was pretty cut and dried - he cut the corner and hit a brick. Not much to talk about there.

 

Anyway - after the piece in briefings I thought i'd better look at the report and see if there was anything I missed, but the link isn't working, nor can I get onto the CYCA website at all. Is it just me?

 

Here's the article from Briefings

 

Learning from the Flinders Islet Tragedy

If there is one thing that we at KORC would like to see all sailors do this year, it’s to review the report recently released by the CYCA on the Flinders Islet tragedy, and to take to heart its recommendations, particularly those based around greater training in the areas of seamanship, navigation and sea survival.

 

On 10 October 2009, the boat Pricewaterhouse Coopers (PwC) was lost after running aground at Flinders Islet, during the Flinders Islet Yacht Race, run by the Cruising Yacht Club of Australia – the same club that organises the Rolex Sydney-Hobart.

 

The CYCA has now released its internal enquiry report, an eye-opener for the yachting world because the set of circumstances that transpired on 10 October could happen to anyone.

 

Pricewaterhouse Coopers was sailed by an experienced crew of eighteen. Eleven of the crew were regular members. The boat was well equipped with both GPS navigational equipment, and safety gear, and conditions were uncomfortable, but definitely not extreme. However, the boat came too close to dangerous rocks, was unable to navigate away from them, and two lives were lost.

 

Brent Marshall – owner of Bird on the Wing and an experienced offshore skipper – has examined the report in detail, and in an email to Yachting New Zealand he says, “I am the last person to promote further regulation, rules and mandatory requirements but this report when coupled with the report into Sydney Hobart fatalities shows we have learnt little from these tragedies. There are many parallels.”

 

He cites seamanship and education as critical to safety, and here summarises the report’s key findings for us. Brent writes:

 

DANGERS OF NAVIGATION BY GPS:

“The way Andrew Short used his GPS and navigated would be identical to the great majority of our racing (and cruising) fleet. The false sense of accuracy and comfort they give is a death trap if the operator does not fully understand the nuances of these devices and People are not aware of the errors that are still in this system.

 

Night navigation is very difficult particularly when close to shore and it is easy to see how these events could happen again.

 

Depth perception is very hard at night and it is very hard to make accurate assessments of range to an obstruction visually. I can easily understand why crew looking at the island were not aware how close they were until the last moments. You can look at an Islet like Flinders at night and nothing much changes until you are very, very close.”

 

SAFETY EQUIPMENT CREATES A FALSE SENSE OF SECURITY:

“The use of PFDs and harnesses is not a simple proposition and can create a false sense of safety. These apparatus are a fundamental safety aid but crew do still need to understand how they work. Do you use the auto inflate? In some circumstance this function is a death trap i.e. under the boat attached to the tether, in others i.e. going into the water unconscious, it is a life saver. The tethers also need to be fully understood. Most use the 2m tether attached to the windward side, this is very dangerous situation if, as Sally was, you are washed over the windward side or the yacht rolls over, if you are not moving around the yacht and just sitting on the rail the short tether is safer but few have and use one. The release of tethers is still an issue, the requirement to have a release at the harness end was implemented because of people drowning similar to what may have happened to Sally but realistically it is not working. A quick release pin is an absolute development the sport must demand of manufacturers. I don’t believe it is possible to release a clip under water with the tether under load. This topic is pretty well covered as part of the advanced sea survival course but there are very few crew who have thought through all these variables and made a plan the works for them.”

 

SEAMANSHIP MUST COME UNDER REVIEW

“The real shock in this report is how poor the basic seamanship was on one of Australia’s premier offshore racing yachts skippered by a very experienced and highly regarded skipper.

 

The rafts by the mast and unstowed, unsecured gear down below were all large contributors to the problems in the 94 Sydney Hobart, and realistic access to a raft was a contributor in the Time to Burn tragedy here in New Zealand.

 

Brent believes the two areas that most need to be focused on here in New Zealand are skipper education – training in GPS and navigation for skipper navigators, especially for those racing at night. The other is that safety harness manufacturers should develop an emergency release mechanism on harnesses.

 

“The GPS in particular has made coastal navigation and night sailing accessible to many who would not normally take the risk,” he says. “Here we have a premier yachtie and race crew who failed in the most basic manner. The further imposition of rules etc is not the answer - we need training and more training.”

Read the report on the CYCA website >

Learn how to survive

The CYCA’s investigation into the Flinders Islet tragedy notes that given the risks involved, the sport of ocean racing has a good record of safety, and the regulation of the sport is effective. Despite the commitment to improvement and safety, accidents have, and will happen.

Royal Port Nicholson’s Todd Olsen writes on the importance of sea survival training and the success of a Wellington based program.

[Guest]

Nothing new there sadly.

 

The key bits being

SAFETY EQUIPMENT CREATES A FALSE SENSE OF SECURITY

and

DANGERS OF NAVIGATION BY GPS:

“The way Andrew Short used his GPS and navigated would be identical to the great majority of our racing (and cruising) fleet. The false sense of accuracy and comfort they give is a death trap if the operator does not fully understand the nuances of these devices and People are not aware of the errors that are still in this system.

 

Brent is spot on the money. Too many slow learners.

[Murky 1]

To me - along with much of the above - the eye-opener was how little time they had (minutes) to formulate a plan to get the crew off the boat, before they ended up with people in the water and being knocked around.

 

The link from the previous thread isn't working for me either Squid but I will email you the copy that was emailed to me.

[Guest]

Nothing new there sadly.

 

The key bits being

SAFETY EQUIPMENT CREATES A FALSE SENSE OF SECURITY

and

DANGERS OF NAVIGATION BY GPS:

“The way Andrew Short used his GPS and navigated would be identical to the great majority of our racing (and cruising) fleet. The false sense of accuracy and comfort they give is a death trap if the operator does not fully understand the nuances of these devices and People are not aware of the errors that are still in this system.

 

Brent is spot on the money. Too many slow learners.

 

Yes true, but I hope they leave it to the Skipper to figure out and not legislate "minimum standards" - that would be an ugly first step towards licensing.

[Guest]

Here's the link for the report page on the CYCA website: http://www.cyca.com.au/editorial.asp?key=4683

[Guest]

Thanks Murky - gotit

[Guest]

I read this when it first came out and from memory they knew the GPS wasn't working correctly, but used it anyway.

[Guest]

Well I have finally waded through the report (I now understand why, whenever someone dies, they report that it cost the country x million dollars – it’s for all the investigations and reports).

 

All I got out of it was they cut the corner and hit the bricks, after that everything worked pretty well as only two people drowned.

 

If I had done this earlier and been the one to send an email to YNZ, the article would have read like this:

 

David Howie – owner of Squid and an experienced offshore skipper – has examined the report in detail, and in an email to Yachting New Zealand he says, “I am the last person to promote further regulation, rules and mandatory requirements.”

He cites seamanship and education as critical to safety, and here summarizes the report’s key findings for us. David writes:

DANGERS OF NAVIGATION BY GPS:

“The way Andrew Short used his GPS and navigated would be identical to the great majority of our racing (and cruising) fleet. The false sense of accuracy and comfort they give is a death trap if the operator does not fully understand the nuances of these devices and People are not aware of the errors that are still in this system.

Night navigation is very difficult particularly when close to shore and it is easy to see how these events could happen again.

 

Depth perception is very hard at night and it is very hard to make accurate assessments of range to an obstruction visually. I can easily understand why crew looking at the island were not aware how close they were until the last moments. You can look at an Islet like Flinders at night and nothing much changes until you are very, very close.”

 

SAFETY EQUIPMENT CREATES A FALSE SENSE OF SECURITY:

“The use of PFDs and harnesses is not a simple proposition and can create a false sense of safety. These apparatus are a fundamental safety aid but crew do still need to understand how they work. Do you use the auto inflate? In some circumstance this function is a death trap i.e. under the boat attached to the tether, in others i.e. going into the water unconscious, it is a life saver. The tethers also need to be fully understood. Most use the 2m tether attached to the windward side, this is very dangerous situation if, as Sally was, you are washed over the windward side or the yacht rolls over, if you are not moving around the yacht and just sitting on the rail the short tether is safer but few have and use one. No piece of safety equipment can be expected to work perfectly in every situation. The skipper should make intelligent informed choices on the equipment he chooses and explain to the crew the reasons for those choices and any limitations the equipment may have. Individual crew members should have a similar attitude to personal gear.

SEAMANSHIP IS NOT THE RESPONSIBILTY OF THE ORGANISING AUTHORITY

“The real shock in this report is how poor the basic seamanship was on one of Australia’s premier offshore racing yachts skippered by a very experienced and highly regarded skipper. Unfortunately it is possible to gather a lot of ocean miles but still be using flawed practices, then one day get caught out.

David believes the area that most needs to be focused on here in New Zealand is skipper education – training in GPS and navigation for skipper navigators, especially for those racing at night. However that responsibility lies with the skipper, all that YNZ can be expected to do is highlight the desirability of education in these areas.

“The GPS in particular has made coastal navigation and night sailing accessible to many who would not normally take the risk,” he says. “Here we have a premier yachtsman and race crew who failed in the most basic manner. The further imposition of rules etc is not the answer - we need education and more education.”

 

 

 

 

 

In spite of all his miles he made some serious errors and they cost him and the other woman their lives, everything else is somewhat less important.

[Guest]

In spite of all his miles he made some serious errors and they cost him and the other woman their lives, everything else is somewhat less important.

 

Or could it be said as 'After doing a gazillion miles complacency set in just a bit too much'?

 

I know I'm, and many crews I've been with at the time, often guilty of doing stuff I know I shouldn't but 'I've got away with it every other time'.

[wal 27]

Slacko, can you remember if there was there any description of what exactly was wrong with their GPS?

 

Not picking up enough satellites for accurate fixes would be a major I'd imagine, in any case, would be the first problem?

[Murky 1]

Lotsa conclusions, hard to seize on any particular one, in my view:

Pricewaterhouse Coopers Incident

173. The Inquiry has concluded the grounding was a genuine accident – an unwanted mishap that was unexpected and unplanned. The Inquiry could not identify a single reason or cause of the accident but we have identified a series of errors in judgement, which by themselves could have been inconsequential, but combined are contributory factors to the tragic grounding. The most significant factor was the general navigation of PwC and this was probably compounded by the inaccuracy of the GPS at the critical time the boat approached Flinders Islet.

174.

The contributory factors identified are:

a. General navigation

i. Lookout and sea room

ii. Reliance on chart plotter and GPS

iii. GPS inaccuracies

b. Organisation of the boat, and

c. Fatigue and overload.

 

175. What is clear is that the incident developed very quickly into a life threatening emergency and was pretty well resolved after only 4 to 5 minutes. During this time the crew were fighting desperately for their lives and effectively unable to go below or draw on any other equipment or support than what they had with them.

Can't reproduce the formatting of the report but i to iii are sub-points of a.

[Guest]

The report is a good read.

 

Everyone who does coastal races and longer should read it.

 

There is an over emphasis on the navigation aids such as GPS and under emphasis on the use of the mark one eyeball. I felt that there was an element of familarity breeding contempt as well.

 

I looked at it from the race management perspective and showed clearly a number of issues in that area which needed improvement.

 

E.G Comunications between race boats and the race managment team, communcations between the race committee and the various agencies involved in the rescues and recovery of the bodies of those who died and finally vertical communciations with in the CCYA.

[John B 106]

There was a statement in there somewhere I read as atmospheric or other interference with the gps accuracy. A contracter who relied on gps had to stop work that night because of it.

[Guest]

But it also said the loss of accuracy was in the order of 100 metres. I wouldn't take an unlit rock at night in bumpy windy conditions at 100m.

 

I also think it quite telling that he had been on the helm for 7 hours (after working all day), had 18? people aboard, one of whom was a competent navigator yet continued to steer, skipper and navigate. He was basically single handing with other people along to provide the muscle.

[Guest]

I pulled this out of the report. It seems to indicate they had on-going errors in the GPS equipment they were aware of.

 

39. PwC experienced a problem with the starboard steering wheel slipping and not functioning properly. This was resolved in about 30 minutes and did not prove to be a subsequent problem. Andrew Short did voice some concerns about the accuracy of the chart plotter and that there was an apparent discrepancy between the displayed positions on the two plotters. This may have been that one chart plotter had reverted to the base chart installed in place of the ‘BlueChart’ card. Andrew also commented after closing the coast and tacking that the boat was closer to the shore than the deck chart plotter indicated. Both systems were rebooted and apparently the skipper’s concerns were satisfied.

 

40. In interviews with the Inquiry some PwC crew commented that they had previously observed errors on the chart plotter. An example was given that on entering Sydney Harbour the plotter indicated the boat had crossed South Reef and the Sow and Pigs Reef when the yacht had clearly been in safe water. A similar example was provided during the Hamilton Island race week. This could have been a problem with the update interval in creating the past track or possibly a setup, installation or calibration problem on PwC.

[Fish 0]

Pricewaterhouse Coopers Incident

173. The Inquiry has concluded the grounding was a genuine accident – an unwanted mishap that was unexpected and unplanned. The Inquiry could not identify a single reason or cause of the accident but we have identified a series of errors in judgement, which by themselves could have been inconsequential, but combined are contributory factors to the tragic grounding.

 

It is very concerning an inquiry into a serious accident (two fatalities) comes up with a statement like this.

 

Anyone with anything to do with Management systems, Safety systems or H&S in general understands that there is NEVER just one cause of an accident. There is ALWAYS a series of small, insignificant events - which in isolation are perfectly inoccous - that accumulate to cause a catastrophic incident.

 

Its called Domino theory.

 

Take one little, minor, unrelated event out of the series and the catastrophic incident is avoided.

 

Unfortunately it is also partly the reason why we have so many pointless regulations, the accumulation of regulations is supposed to make us safer. At the end of the day its really just an individual doing some small, inconsequental action thats breaks the domino, and they wouldn't even realise it.

 

Take for example Squid always applying sunblock on passage - stops him getting sunburnt and dehydrated - means he can do his nav properly and have good judgment (allegedly ) You can't (or shouldn't) legislate that everyone applies sunblock on passage. You can learn / educate that if you are over tired - dyhrated - sunburnt - worked all day then helmed for 7hrs doing nav and tactics - you make poor desicions that accumulate into a dirty great "catastrophic incident".

 

No regulations required.

[Guest]

Fish - an example I often use when people ask why kids on boats are more responsible.

 

I tell them to do the dishes.

To me that means wash , dry , put away, clean the galley, nothing left out. If they take a shortcut and leave a glass on the counter. At 3 am I need to reef, come below for my boots, the glass has jumped the fiddle and broken, I cut my foot, rref is delayed 2 mins, mast comes down, boat sinks, we all die.

 

 

Sounds silly but could easily happen. I know now 5 years after moving ashore that if I give one of them a job it will be completed and tidied up.

 

I think this skipper made a string of small errors (some of which he had probably got away with in the past as KM says) - all reported, then one big one. I don't think the authorities need do any more than publicise it a little (difficult - there are friends and families to consider).

[Murky 1]

The 15 crew members that didn't get swept overboard were able to step on to the island, without even needing to get in the tide or into a liferaft - if that had been the case for everyone, it would have just been a race yacht wrecked in Oz and we probably wouldn't have even heard of this incident.

 

Very valuable report though, even down to the model of torch that many of us would carry on board, proving not up to the task.

[Fish 0]

So I've read the majority of the report now, very interesting.

 

I feel the inquiry has missed a blindingly obvious root cause to this accident:

 

Relying on one system only for navigation.

 

The key point here is that they smacked full tit into some rocks at night. After that and I have to say the safety systems worked exceptionally well to have 16 crew quickly rescued, 15 without practically any stress at all (comparatively).

 

I thought race boats had to carry at least one hard wired GPS system and numerous spare hand held GPS's.

 

Look at this for a scenario:

Use chart plotter for easy nav, plenty of data outputs like distance / time to go etc. All inputs are electronic - blue charts, datums, off sets etc etc

You NEED a cross check - take a cheap arse hand held GPS - input a waypoint from a paper chart. Use that waypoint as a safe water mark clear off the Islet. If either couse / bearing diverges then the cross check fails and you are aware you have an issue.

 

You may say you are still relying on GPS in both situations - No. By taking a waypoint from a paper chart and a heading from the chart plotter you are cross checking datum errors, chart update errors etc, thats one source of risk covered.

 

For poor GPS accuracy, if two units diverge again you will see incresed inaccuracy, both units should match, if they are +/- 100m this can be seen. If you only have one system you are stuffed.

 

Contributing Factors:

Having 18 crew onbaord and not having a dedicated navigator? A bit odd.

 

Domino theory probably started at the broken headsail halyard just out of Sydney Heads. This caused the bowman's shoulder to dislocated and was put into a bunk.

On approaching Flinders Islet the tactician was doing foredeck - they where doing the usual pissing around changing the kite selection at the last minute for the hoist after rounding.

 

This meant the afterguard was one short, i'm infering the driver was then focused on kite selection / tactics and no one was really thinking about Nav. The wind had lifted 40deg and they took the height - they were then over standing the Islet - again from the report an inference that no one was actually checking where they were in regards to the islet.

 

Comes back to division of labour and assigning clear responsibilities. Tactician on the foredeck, driver doing everything else - 16 crew on the rail...

 

There is really only one other point for Race Organisers to consider. Sending boats around an unlit Islet at night. The cotton wool brigade may query this. The report was very clear that ocean racing carries inherent danger. If anyone says its too dangrous to do this then we may as well give up now.

 

All crew had personal locator beacons, all crew were listed and named. There was confusion over crew numbers held by the RO - this had no bearing on anything. I think the safety systems and equipment where second to none - much more stringent than in NZ. There was criticsim the Port Kembla Port Authority didn't know the race was on - so? A pilot cutter happened to be nearby - as were 4 race boats in the first instance and a police launch. The RO basically had no idea what was going on - poor radio coverage and incorret crew numbers. I don't see this as relevant as the State rescue authority are the incident controllers - the same would apply in NZ. RO's aren't going to coordinate SAR operations. They could do with accurate info though.

 

The issue was boat management. One guy doing everything - no division of labour or responsibilities - and relying on one system for navigation.

[Guest]

There is really only one other point for Race Organisers to consider. Sending boats around an unlit Islet at night. The cotton wool brigade may query this. The report was very clear that ocean racing carries inherent danger. If anyone says its too dangrous to do this then we may as well give up now.

Seems to me that the yacht club and the boats racing were all well experienced in racing at night, offshore, around bits of rock. Sure its dangerous, but these guys knew what they were heading into.

 

What surprised me was how unprepared race management were for something to go wrong.

 

Question for you all: for your offshore races, how prepared is your race management for dealing with an emergency?