Fatality Report on Chicago Mackinac Race

[donradcliffe]

A disturbing incident report on a MOB from a TP52 who died in broad daylight half an hour after the start last summer. Many mistakes were made, but his inflatable life vest failed to inflate automatically, and he didn't attempt to manually inflate during the 15 minutes between the time he went overboard and when he went under. The other big problem was the difficulty the TP52 had in getting close to him in 20-25k of wind--they didn't drop their sails because they thought it would take too long,

https://www.sailingscuttlebutt.com/w...ent_Report.pdf

[Richard5]

I am just to page 12 of the report. So far, I think page 9, beginning with 6.3 says it all.

The quote on page 10, 6.6; "someone snug the vane' is indicative of a crew, while individually highly experienced, are not acting as a tight crew. This point is further elucidated in the following pages and previously where mentioned on page 9 about the short brief which apparently was scant.

Given that three of the crew had no Safety At Sea (SAS) training, I wonder which of the crew had made the comment, "people onboard weren't frantic because Jon wasn't frantic" (page 11, 6.7.5). There are several reasons why a MOB may not be showing heightened emotion and most are not good. That is to say, the condition of the MOB is a poor standard by which to judge the urgency of response.

I am not looking to blame. My intent is to highlight that any crew - no matter the level of experience of each individual crewman - must first train as a crew before putting to sea. This applies also in the case where some but not all crewmen have shipped together before. In fact, the high level of experience of each may act to put off that briefing and/or training because it may be considered 'basic' or 'remedial' training.

[Island Time O25]

Why is this a crew issue and not a skipper issue or chain of command issue if the skipper was MOB? Or did the crew lack formal command ladder?

[requiem]

I had similar thoughts regarding the organization aboard, and I think this item from Appendix G really says it all:

Normally the communication was very effective onboard, and everyone knew what to do. However, that management style worked fine until someone was in the water. Then people were out of place and people either didn’t respond or too many people responded to orders.

Reading the timeline, I didn't recognize any particular recovery method (e.g. figure 8, quick stop, etc.). The report also mentions that Imedi needed six people to drop the main, and two for the jib.

My sense is that their urgency to get back to the MOB prevented an effective approach: if the timing in the report is correct they managed two passes in a matter of minutes, but they also wrapped the jib and weren't able to stop the boat near the MOB.

[Richard5]

Originally Posted by Island Time O25

Why is this a crew issue and not a skipper issue or chain of command issue if the skipper was MOB? Or did the crew lack formal command ladder?

My opinion is it is both. Much effort by the crew was performed on an individual basis, not as a unified crew. One example, none took it upon themselves to throw a MOB pole. Another example, each decided for himself to not offer redundancy in spotting. This in a pitching boat with persons being thrown about. Third example, the absolute circle jerk in attempting to drop the jib while short handed then finally getting it so wrapped that it became stuck. And that is incredible to say given there were twelve experienced sailors aboard at the time. Fourth example, uncoordinated efforts between the helm and the foredeck resulting in injury.

But if put into a hierarchy it rightfully falls to the skipper. 'Person In Charge' (PIC) in this case is a title only and not indicative of competency to lead. Perhaps this issue arose before they left the dock, what was the basis for why the owner selected that particular person to be PIC in his stead?

I had to take a break from reading the report as my blood began to boil from the apparent cluster. I wonder what the USCG inquiry advised for.

[Richard5]

Originally Posted by requiem

My sense is that their urgency to get back to the MOB prevented an effective approach: if the timing in the report is correct they managed two passes in a matter of minutes, but they also wrapped the jib and weren't able to stop the boat near the MOB.

Don't forget that with the engine now on the vessel turned tighter than the helm expected (maybe it is only the writing style but I I got the sense that the helm was surprised by the tight turning) so now the vessel overrode the MOB resulting in a submerged MOB and possibly with injuries.

[gamayun]

Originally Posted by Richard5

I am just to page 12 of the report. So far, I think page 9, beginning with 6.3 says it all.

The quote on page 10, 6.6; "someone snug the vane' is indicative of a crew, while individually highly experienced, are not acting as a tight crew. This point is further elucidated in the following pages and previously where mentioned on page 9 about the short brief which apparently was scant.

Given that three of the crew had no Safety At Sea (SAS) training, I wonder which of the crew had made the comment, "people onboard weren't frantic because Jon wasn't frantic" (page 11, 6.7.5). There are several reasons why a MOB may not be showing heightened emotion and most are not good. That is to say, the condition of the MOB is a poor standard by which to judge the urgency of response.

I am not looking to blame. My intent is to highlight that any crew - no matter the level of experience of each individual crewman - must first train as a crew before putting to sea. This applies also in the case where some but not all crewmen have shipped together before. In fact, the high level of experience of each may act to put off that briefing and/or training because it may be considered 'basic' or 'remedial' training.

In an appendix of the report, there's a part that lists the signs of drowning and they're not the ones that are depicted on TV. Other witness reports like this one I've read have said things like, "It didn't look like they were in distress."

This is also telling to me: the CG trains their personnel to the point of “muscle memory” to
pull the manual inflation cord on an inflatable jacket when they hit the water, and not to even wait
for the automatic feature to function. I've heard that many people tend to tuck the inflator pulls into something because they can snag and accidentally inflate the PFD. Finding the inflator cord with eyes closed should be part of every COB drill.

[Richard5]

Originally Posted by Richard5

Don't forget that with the engine now on the vessel turned tighter than the helm expected (maybe it is only the writing style but I I got the sense that the helm was surprised by the tight turning) so now the vessel overrode the MOB resulting in a submerged MOB and possibly with injuries.

Per Medical Examiner's report (psge 55, Appendix L) I delete my speculation of injuries to the MOB by the vessel.

(I leave the previous text whole for the sake of consistency.)

[Richard5]

Originally Posted by gamayun

In an appendix of the report, there's a part that lists the signs of drowning and they're not the ones that are depicted on TV. Other witness reports like this one I've read have said things like, "It didn't look like they were in distress."

I was an ocean lifeguard for a few years. My brother was the same but for about 18 years. Several times he told of being hassled by parents who sat on the beach watching their kids drown. The parents hassled him because they thought he was needlessly bothering their little ones. Many guards had had the same experience.

This is also telling to me: the CG trains their personnel to the point of “muscle memory” to
pull the manual inflation cord on an inflatable jacket when they hit the water, and not to even wait
for the automatic feature to function. I've heard that many people tend to tuck the inflator pulls into something because they can snag and accidentally inflate the PFD. Finding the inflator cord with eyes closed should be part of every COB drill.

This cannot be said often enough.


If you want to know the proper way to do something look to the military for guidance. This 'muscle memory' training is a very good idea.

My dad was a dive instructor and dived salvage for the U.S. Navy. From early on we were always taught to keep the cord free and accessible. This point was repeated so often I can still hear it. Also, finding with eyes closed and/or in turbulent conditions was part of the learning. This transferred directly to all flotation gear used in sailing and flight over water.

Tucking the cord is tantamount to an unauthorized modification of a flotation device. It reminds me of one 'playing to their weakness' rather than effecting a change of behavior.

[Snore]

The fact that the “person in charge” never deployed the life sling AND no one said “let’s deploy the life sling on the next pass” to the PIC, says it all.

[Suijin]

I've done a bunch of these races on big sleds. There are a bunch of things these guys did wrong, despite their training and their experience, and in my opinion part of the problem is taking safety procedures for granted while another part is the type of the boat and the size of the crew. Lastly, there is decision making and communication during the "fog of war".

As far as safety procedures and training go, race requirements are that a certain percentage of the crew have SAS training. With the crew of a TP52 you can be fairly certain that an excess percentage have this training because your crew pool is experienced. You don't bring a lot of "rail meat" on to a TP52 because it's dangerous. However, I suspect that not all the crew members were regular team and had trained together other than a practice run or two the day before. Needing 13 crew you draw from your pool as available for a specific event.

But SAS training, while extremely informative and useful, is only as effective as the specific training that you engage in afterwards on your boat. In MOB scenarios, SAS only outlines best practices and standard procedures. They may, in the case of the seminar held at the Naval Academy, do a demonstration in the Severn but you're just watching highly trained mids on the offshore team do a quick stop and recovery on a Navy 44. They make it look easy of course because they've done it probably a hundred times.

Pretty much every boat in a race that requires that you perform a practice recovery is going to do the "toss a cushion in the water and go back and get it" routine and call it a day. Usually in flat water. Some bigger boats will do a real exercise and it's always eye-opening how difficult it is in even moderate conditions. But the first thing you do is drop the sails and get control of the boat and get it headed back to your MOB. That and keeping visual contact with the MOB are the obvious priorities.

But the problem on a TP52 is how complex the boat is and how unstable it is. If you do things wrong on that boat it breaks and/or people get hurt as the rig is huge and the forces at work can be enormous. The PIC's decision to keep the sails up was a judgement call about how to best get back to the MOB and may have been made based on crew cohesion or confusion of the moment. However it's clear to me that even so once the boat was stopped and in the general vicinity of the MOB the crew should have focused on getting the sails down. They probably thought that getting back to him and getting him a line or whatever was the priority. In truth, the fact that they got back to him in less than 90 seconds, on that boat, is pretty amazing. But had they taken another minute to get the sails down and gotten to him in 150 seconds the outcome would have likely been different.

It sounds like they did not know the brand of the PFD, but with a Hammar MA1 inflator it could well have been a Mustang with integrated harness. I know on this PFD and similar that if the inflator does not work (automatically or by pulling the tab) that to manually inflate it you need to open up the jacket and unfold the bladder to get to the blow up tube. If you don't know how to open the jacket lining you're not going to access that tube. Everyone should know how to do that with their PFD.

I think the report does a really good job of analyzing the the causes and making recommendations. That said, I think it's optimistic that many boats will invest the organization and time into implementing all of the recommendation outside of professional crews.

[requiem]

Originally Posted by Suijin

But the problem on a TP52 is how complex the boat is and how unstable it is. If you do things wrong on that boat it breaks and/or people get hurt as the rig is huge and the forces at work can be enormous. The PIC's decision to keep the sails up was a judgement call about how to best get back to the MOB and may have been made based on crew cohesion or confusion of the moment. However it's clear to me that even so once the boat was stopped and in the general vicinity of the MOB the crew should have focused on getting the sails down. They probably thought that getting back to him and getting him a line or whatever was the priority. In truth, the fact that they got back to him in less than 90 seconds, on that boat, is pretty amazing. But had they taken another minute to get the sails down and gotten to him in 150 seconds the outcome would have likely been different.

Not being familiar with such boats I was surprised to read that it couldn't reef and took 6 people to lower the main. To me an immediate decision is whether to drop the sails or attempt a recovery under sail. Ideally this has already been determined based on conditions before anyone goes over. Just as I couldn't recognize a standard recovery maneuver, I couldn't identify anyone as being in charge.

Originally Posted by Suijin

It sounds like they did not know the brand of the PFD, but with a Hammar MA1 inflator it could well have been a Mustang with integrated harness. I know on this PFD and similar that if the inflator does not work (automatically or by pulling the tab) that to manually inflate it you need to open up the jacket and unfold the bladder to get to the blow up tube. If you don't know how to open the jacket lining you're not going to access that tube. Everyone should know how to do that with their PFD.

Since the report mentions a common pool of PFDs I'm very disappointed that the remainder were not made available for inspection. That would give a good idea of the likely model as well as the overall state (e.g. were all the inflators long expired?). Test inflations of each would also indicate if there was a systemic problem.

Originally Posted by Suijin

I think the report does a really good job of analyzing the the causes and making recommendations. That said, I think it's optimistic that many boats will invest the organization and time into implementing all of the recommendation outside of professional crews.

Optimistic, yes, but I wouldn't consider these recommendations as much beyond established best practice. The only item I'd consider "new" is item V, actively pulling the manual inflator by default. Almost all the others, even if oft-neglected, are or should be part of current practice and training.

[boat driver]

all these comments point at the boat.
may suggest all people begin with an interesting factual understanding on pg 35 bottom- Inflatable life jackets are 8.7 % failure to inflate. Might I suggest that to begin with the rules of life jackets (inflatable) tied around a sailor with crotch straps and leg straps, and the AIS PLB installed are all relying on a single fact... so in reality- ten people on board a vessel- who gets the short straw? The US Sailing rules are dated April 13, 1912.....

[Boatguy30]

I knew many people onboard. It simply wasn't a team up for racing that type of boat in those conditions

[donradcliffe]

It sounded to me like the crew was not used to working together as a team--for example, the person in charge of the running backs should know that failure to tend them in tacks and gybes can easily result in the loss of the rig and more damage and injury--but they were negected.

It takes 6 people and about 3-5 minutes get get the main down. First you have to find and rig a snatch block to guide the halyard to the primary winch. Then you have to prepare about 180 ft of halyard tail so it will run without tangling. Then you have to ltension the halyard on the winch to unload and lock out the jammer. Then you have to drop the sail and make sure it doesn't go over the side--you also have to pull the boom down with the mainsheet winch after you start lowering.

I would have assigned 4-5 people to get the jib down on the first tack--one on the halyard winch and jammer, and 3-4 on the foredeck to get it down and lashed. Whoever said 'no' to the jib drop made the wrong call. While the boat may have stalled in irons, it would have easily been brought out of that by using the motor, which they needed anyway.

The investigating team missed one important piece of information--what was Jon wearing when recovered?. The Larry Klein tragedy in SF Bay demonstrated that even strong, fit crew can't stay afloat if they have full foulies and seaboots on. You need a pfd or other flotation device within less than 5 minutes. Try it sometime.