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Old 14-11-2013, 06:28   #1
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"Accidents" they are not: An encounter with Swiss Cheese Theory

At the risk of being ridiculed, I thought I'd tell about a past encounter with near catastrophe as a good example of the Swiss Cheese model of accident analysis.
After several days at sea in calm to moderate conditions we found ourselves jibing downwind with full main and ASI in TWS 15kts.
Slice 1: The crew included a moderately experienced captain (me), and two relatively inexperienced friends who had each done a charter or two in friendly waters.
Slice 2: We unexpectedly noted that the wind speed indicator had failed, although wind direction appeared accurate. A reset did not correct the matter and we sailed on.
Slice 3: A lack of observation possibly due to fatigue and the usual reliance on the instruments resulted in me failing to note a sudden increase in wind speed and it was not until we suddenly sustained 18.5kts for about 40 seconds whilst surfing that the danger of being overpowered was realized.
Slice 4: Considering the strengths of the crew, I mistakenly decided that I would go forward to bring down the sock of my 155Sqm ASI and instructed my two less experienced crew as to their roles, one to steer the boat close to down wind and the other on the timing of releasing the sheet. Upon reflection, the danger demanding greatest experience was in the steering of the boat which I should have done.
Slice 5: Once near direct down wind, the sheet release was too slow and the time to get the sock down was drawn out lengthening the time of vulnerability.
Slice 6: The helmsman, no doubt became distracted by the struggle to get the sock down, and failed to maintain the heading. Perhaps the confused sea contributed to some windward wander, and so the boat with full main began to round up, no longer having a balanced sail plan. We settled beam on.
Slice 7: Yelling loudly from the bow, whist now wrestling a half doused sail flailing out to leeward and unable to draw the sock down, I "asked" that the boat be turned down wind.
Slice 8: During all this commotion, the two crew at the helm failed to note that the lazy sheet was now in the water and had tangled the rudder. Matters were exacerbated when the engines were started in an attempt to turn the bow down wind.
Slice 9: "The engine won't start and I can't turn the rudder" was the reply. "Fu*K" was mine. By now the Spinnaker was blown out and in shreds. We were beam on to the sea and drifting without rudder or port engine towards the beach some 1 to 1.5NM away, and with the risk that whatever sheet was in the water could still foul the STBD engine if used. There was nothing to do but cut the ASI free and retrieve the halyard and sheets as the sail was quickly on its way, fortunately away from us.
Slice 10: I tied on to a strong line and jumped from the stern landing on a jelly fish whose stingers envenomated about a quarter of my thorax. in mounting seas, I avoided with luck, being battered between wave and hull and managed to cut and free the sheet that had entangled the rudder and propeller.

And so, we now had steering, and power and were back sailing with a more conservative (although less exhilarating) sail plan. I did get some throat swelling from the effects of a large area of envenomation and this settled with a large doses of antihistamine and steroids. It was all now so tame, although only a brief time earlier, we were facing the prospects of drifting onto the beach about 1NM away.

So ultimately the cost was that of a new ASI, but it could so easily have been very much more, not to mention personal safety issues. Upon reflection, I count 10 opportunities to alter this fateful path. Ten opportunities missed! This time we were lucky. I trust there will be no next time as I hope to learn from my experience.
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Old 14-11-2013, 06:37   #2
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Welcome to the club of hard knocks. Anyone who ridicules you hasn't sailed much.

You learned, and you and your boat get to sail another day.
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Old 14-11-2013, 07:29   #3
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Oh well s**t happens and you were able to overcome a potentially dangerous situation and learn from it.
Congratulations you again will get to sail and experience yet another insult from mother nature when she decides to mess with you!
BTW I see you are from Australia........there is some guy down there by the name of Jimmy Spithill who may be looking to crew.
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Old 14-11-2013, 09:14   #4
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

It is good to hear that both you and the crew survived the experience. From your post, I believe you have had a good albeit expensive lesson.
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Old 14-11-2013, 09:26   #5
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Good story, and decent analysis. I had almost the exact experience once, and responded in the same way you did (me on the front trying to douse the sail while a relatively inexperienced crew member steered us in the wrong direction), with some equipment damage but no loss of crew.

Thanks for sharing. Many of us have been there to some degree at least.
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Old 14-11-2013, 10:13   #6
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Extremely valuable post .

I do some teaching on the side with a certain business school. We write cases for the students, and for students of many other business schools around the world. The most interesting cases, by far, concern failed projects. The thing is, no one wants to talk about their failed projects or businesses, and this is a huge problem.

Therefore, I salute you, sir, for the extremely useful and excellently written and analyzed post.
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Old 14-11-2013, 10:24   #7
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Thank you for the story. It is definitely enlightening.

Sounds like you may have the same problem that I do when it comes to assigning tasks. I tend to forget that even though steering is simple it takes an experienced person to do it well and safely. And that I have a hard time delegating other tasks because it is just easier to do it yourself.

Don't forget people that have accidents made a mistake, people that narrowly avoid accidents gain experience. One is revered the other is looked down upon. Don't beat yourself up just learn from it.
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Old 14-11-2013, 10:47   #8
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Yep a fine day of "sailing"....
“Experience is something you don't get until just after you need it.”
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Old 14-11-2013, 11:48   #9
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

thanks for sharing!

Best point from this as you know, for others to learn, is to keep the bow pointed downwind when caught like this. Rounding up or jibing are to be avoided at all costs.
I have done this with less experienced crew at helm, but always inshore, where I could identify landmark and say "steer towards that- DO NOT do anything else"
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Old 14-11-2013, 13:25   #10
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Thanks for the story and the analysis ... good to read the accounts like this, reflect and learn.

Long time ago, I was in a similar predicament and although I stayed at helm and in command, I still lost the sail. The inexperienced crew just could not deal with the sail and conditions no matter how well I tried to steer. Things happen ... glad it was just a sail that was lost.
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Old 14-11-2013, 13:35   #11
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

That's a great story and useful post.

Helming is not as easy as one would think, and when you have a lot of hours you get very good at sailing with the wind on the back of your ears and other sensory input that you hardly think about. New at the helm, trying to use a compass, it is easy to screw it up when things get exciting. A few nights surfing off the wind and you get pretty good feel for it.

Have to admit I got a little knot in my stomach reading it, once the sail blew out and the sheets were fouled. That blows....
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Old 14-11-2013, 15:44   #12
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Depends how big your ASI was, but 18.5 kts (I assume true wind) is not much to take it down. Mine is 150 sqm and I can fly it up to 25 true. If it goes beyond, I first unfurl the gib and then take the ASI behind it. As the gib takes most of the wind , it is much more easier and less risky to pull the ASI down.
I happened to fall mine in much moderate conditions once (by the mistake of the admiral of course ) Fortunately I had learnt to not to start the engine and I managed to pull out the ASI in 45 min. w/out having to swim. (sea water was 15 degrees C..)
Given the conditions, I believe you handled the problem pretty well..
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Old 14-11-2013, 17:20   #13
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Quote:
Originally Posted by yeloya View Post
Depends how big your ASI was, but 18.5 kts (I assume true wind) is not much to take it down. Mine is 150 sqm and I can fly it up to 25 true. If it goes beyond, I first unfurl the gib and then take the ASI behind it. As the gib takes most of the wind , it is much more easier and less risky to pull the ASI down.
I happened to fall mine in much moderate conditions once (by the mistake of the admiral of course ) Fortunately I had learnt to not to start the engine and I managed to pull out the ASI in 45 min. w/out having to swim. (sea water was 15 degrees C..)
Given the conditions, I believe you handled the problem pretty well..
Yeloya
I think the post was 18.5 knots BOAT SPEED at least that how i read it which would defo have me pretty nervous with a 155 sqm ASI up and inexperienced crew.

Well done on a good "save" and great analysis of how each little problem often stacks on top of the other for an eventual big problem. Thats sailing though...
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Old 14-11-2013, 17:37   #14
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Re: "Accidents" they are not: An encounter with Swiss Cheese Theory

Thanks for sharing that story! It's amazing how coming up can increase not only wind speed, but boat motion as well.
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Old 14-11-2013, 17:47   #15
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Classic event cascade. We'd all be better of we could predict such cascades. But then we never seem to....

I suspect you would have lost that sail one way or the other


I was on a recent delivery ( 45 footer) with the owner , a keen racer, and one of his crew. The AS was dragged out , " no good ever comes from that sail says I " , after three collapses, and almost getting it over the side , it went back into the nice bag and stayed there for the rest of the delivery, which went very un eventfully . I mean its not like we were slow.

I race an 8 m beneteau , we have 5 onboard , all good racing crew and then we fly the kite.

Dave
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