I was on the incident investigation panel.
I just wanted to clarify a few things (these are my thoughts not necessarily the official panel conclusions):
1. It's an important tactical decision in this race
whether to go inside or outside the islands. In previous races the skipper
of Aegean set a waypoint a mile or so in front of the islands to signal they needed to make a decision which way to go. And they used waypoint alarms.
Normally it is good practice to offset waypoints away from hazards so you will not run into the hazard if you over run the waypoint a little. However, in this particular race
, the tactic of putting a waypoint just in front of the island is reasonable to allow you to decide which side to go with the minimum distance wasted. But if so you sure want to be paying attention when you arrive at that waypoint.
2. In previous races they did run radar
but did not use a guard zone alarm
because there were so many targets (race boats) it would just be going off all the time. However if they had set a small guard zone (say 1nm) it would still have given them time to react and would not have had too many 'false alarms', at least a few hours after the start as the competitors were spread out.
3. In previous races there were always at least 2 on watch at night, never did they leave only one on watch. The skipper
usually went to sleep for an hour during the night motoring period.
4. The weather
was calm (5kts of breeze) calm seas but a long ocean swell that was breaking on the island. It was clear with good visibility but dark with the moon just set.
Assuming they did these things as they had in previous races, then you have to conclude that at least a couple people on watch were for some reason not paying attention to a known hazard and that they did not hear or respond to the waypoint alarm
. Unfortunately the human body likes to sleep at 1:30am and you really need to exercise discipline to stay alert then. There are historic procedures that have been developed to help crew stay alert - like regularly making log entries and plotting positions and setting timers to do every 10 minute horizon and radar/plotter scans, etc.
The autopsy reports found no indication of CO poisoning and no alcohol. My personal conclusion is that they were complacent after doing 6 of these races and just fell asleep.
4. Some of the crew were alive and alert after the impact as someone pushed the SPOT SOS button approximately 7 minutes after the impact. Unfortunately this SPOT SOS message did not get communicated to the authorities and no search was launched until the next day when other vessels found the debris field. A DSC
may day would have been much more effective (with all the racing
boats near by) but it may be that their mast
fell down quite quickly on impact. An EPIRB
would also have been more effective (USCG san diego
would have launched assets within 30 minutes with a gpirb signal) but they did not have an eprib.
5. I believe the natural human inclination in this situation would be to try to swim toward land but in this case there was no safety
that way only rocks and a cliff. They might have survived if they had tried to swim out away from land but at night they could probably not see that. Water
temps were 62F. They died of blunt trauma, bashed on the rocks by the swell (3 died directly from blunt trauma and one drown due to traumatic injuries).
6. None of the bodies were wearing pfd's. When you abandon ship you should really don a pfd
Bottom line . . . we all make mistakes
, unfortunately the outcome was truly severe in this case. I am still surprised that all died in this incident. It is an intense reminder of the basics of seamanship - keeping a real watch at 1:30am, navigating to avoid hazards even if you miss a waypoint, and properly making mayday/abandoning ship.