The UK’s Marine Accident Investigation Branch (MAIB) has today published its final report into the grounding of CV24 in South Africa, which took place on 31 October 2017 during the third leg of the Clipper 2017-18 Round the World Yacht Race.
The report recognises that Clipper Ventures responded immediately to the incident by;
-Recruiting mates for each of the eleven race teams, in addition to the Clipper Race Coxswain crew members on board each yacht which was an existing safety measure agreed with the MCA.
-Creating an internal Safety Audit Department, led by the Chief Operating Officer
-Introducing compulsory exclusion zones from all coastlines, islands and off lying hazards between race start and the finish line, including rules that no Clipper vessel is to roam into an area less than 20m deep (chart datum) between race start and the finish line.
-Introducing a procedure whereby all passage plans are checked by company staff prior to the start of each race leg.
The report goes on to highlight a number of factors which contributed to the grounding, and makes various recommendations, most of which were already actioned by Clipper Ventures directly following the incident, as detailed above.
Safety has been Clipper Ventures’ highest priority since the Clipper Race was established in 1996, amassing huge experience through eleven biennial editions, 97 yacht circumnavigations (a cumulative excess of 4 million nautical miles) with over 5000 crew undergoing extensive training, plus the successful running of three Velux 5 Ocean Races.
Reacting to the report, Clipper Ventures Founder and Chairman Sir Robin Knox-Johnston says: “Clipper Ventures, which is currently completing its fourteenth around the world yacht race, is committed to maintaining the highest possible safety standards across its training and racing. This incident brings up vital learnings for all yachtsmen.
“As part of our investigations, we were most concerned that a number of yachts were ignoring the race instructions’ advisory warning to remain at least 10 miles offshore at night. As a result of this incident we immediately implemented mandatory exclusion zones around navigational hazards. We also implemented new guidelines to Skippers and our Race Officials are now monitoring the quality of all passage plans going forward. We are confident that these two initiatives will significantly reduce the risk of such an incident occurring in the future.”
Sir Robin adds: “Clipper Ventures runs a safety management system which exceeds all regulatory requirements and recommendations. As a result, we have been at the forefront of implementing safety initiatives to ocean racing such as AIS beacons on Dan buoys and in Lifejackets, a system now being introduced by World Sailing, double tethers on harnesses, sea survival training for all crew, ISAF survival training, and swimmer assisted MOB recovery using dummies. Nevertheless, we are always looking for ways to improve and continue to review our systems to make sure they remain at the forefront of best practice.
Concluding, he says: “The lessons for our industry at large are significant and a review of regulation, and the speed of reporting of key learnings, is urgently required. It is unreasonable to expect individual companies such as Clipper Ventures to path-find on safety without the support and encouragement from the relevant authorities.”
The following sections are taken directly from the MAIB report and explain the Conclusions, Actions Taken, and Recommendations in the report.
Section 3 – Conclusions
3.1 Safety issues directly contributing to the accident that have been addressed or resulted in recommendations:
1. As the true wind backed to the predicted north-north-westerly direction, the crew of CV24 focused on maintaining a safe apparent wind, which resulted in the yacht being sailed close inshore. [2.3.1]
2. The skipper was aware of the danger ahead and the need to gybe but had not allowed enough time for the watch on deck to conduct this evolution for the first time together in the dark. [2.3.2]
3. The skipper was the only person monitoring navigation and became distracted from this task by the requirement to supervise the gybe evolution. [2.3.3]
4. The skipper’s lack of access to navigational information, the depth information not being displayed at the port helm station and the hazy conditions meant that no-one on board CV24 appreciated the immediate risk of grounding. [2.3.3]
5. After the gybe, the skipper and crew on deck did not have sufficient positional awareness to appreciate that CV24 was not heading away from danger as perceived. [2.3.3]
6. There was insufficient planning for the coastal passage and no safeguards were in place to warn the skipper or crew of danger. [2.7, 2.8]
7. Had a route with cross track distances been plotted in Timezero, it might have been more evident to crew in the nav station that CV24 had departed from a safe route. [2.8, 2.9]
8. The presence of other yachts in CV24’s vicinity might have induced a false sense of security. [2.3.3]
9. CV24 did not have a nominated navigator with the experience, authority and guidance to prepare and monitor a passage plan on behalf of the skipper. Provision of such a role on board Clipper Ventures’ yachts had been recommended to the company in 2010. [2.5]
10. With only one professional, employed seafarer on board, the Clipper yachts were not safely manned for the round the world race. [2.6]
3.2 Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations:
1. The watch leader did not have the appropriate qualifications or experience to be delegated responsibility for maintaining a safe navigational watch as required by the SCV Code. In addition, Clipper Ventures provided no additional training for the watch leader role. [2.6]
2. Navigation did not form part of levels 1 to 4 of the pre-race training syllabus for prospective Clipper Ventures’ crew. [2.5]
3. Clipper Ventures’ safety management system was not providing sufficient supervision and assurance to ensure safe operations, specifically:
-The risk assessment and procedures for coastal navigation were not effective. [2.11.2]
-Opportunities to improve coastal navigation standards by learning lessons from previous groundings were not taken. [2.11.3]
-Key members of staff with responsibility for delivering operations did not have guidance or terms of reference for their safety management responsibilities. [2.11.5]
3.3 Other safety issues not directly contributing to the accident:
1. Seven other yachts followed tracks similar to CV24’s towards the shore, and CV31 almost certainly grounded. [2.4]
2. There was an unnecessary delay of 50 minutes in notifying the emergency services. [2.10]
3. The South African rescue services’ response was swift and effective, ensuring the safety of the crew of CV24. [2.10]
Section 4 – Actions taken
4.1 MAIB actions:
On 17 November 2017, the MAIB issued Recommendation 2017/151 to Clipper Ventures plc that recommended the company to:
Take urgent action designed to improve the ability of its skippers and watch leaders to maintain positional awareness while on deck in pilotage and coastal waters. Consideration should be given to:
-The provision of a navigation/chart display on deck by the helm position.
-More effective use of onboard navigational equipment to avoid danger, including a means for rapid communication between the navigation station and the helm.
-More clearly defining the duties of the watch navigator.
4.2 MCA Actions
The Maritime and Coastguard Agency has directed that Clipper Ventures’ yachts are to be manned at all times as required by the SCV Code.
4.3 Clipper Ventures actions
Clipper Ventures plc has:
-Responded to the MCA’s decision to require manning of yachts in accordance with the SCV Code by recruiting a qualified mate for each yacht in the round the world race.
-Created an internal company Safety Audit Department, led by the COO. The Safety Audit Department’s role is to investigate accidents and promulgate the lessons learned.
-Updated its race instructions to Clipper yacht crews, introducing a compulsory exclusion zone described as:
There will be a 2nm exclusion zone from all coastline, islands and off lying hazards (awash or above the water at chart datum) between Race Start and the Finish Line.
In addition to the above, no Clipper vessel is to roam into an area of less than 20m deep (chart datum) between Race Start and the Finish Line.
-Introduced a procedure whereby round the world skippers’ passage plans are checked by company staff prior to the start of each race leg.
Section 5 – Recommendations
The Maritime and Coastguard Agency is recommended to:
2018/116 Provide guidance and direction on safety management to Clipper Ventures plc in order to assure the safe operation of the company’s yachts in accordance with the Small Commercial Vessel Code.
Clipper Ventures plc is recommended to:
2018/117 – Review and improve company safety management procedures in co-operation with the Maritime and Coastguard Agency and aligned with the guidance proposed in MAIB recommendation 2018/116 above.
This review should ensure that:
-Risk assessments for on-water operations identify all hazards and set out appropriate mitigating measures.
-Accidents and incidents are thoroughly investigated so that causal factors and lessons are identified in order that, where necessary, changes are made to company procedures to minimise the risk of recurrence.
-There is guidance and terms of reference for members of staff with responsibility for safety management.
2018/118 – Update procedures for the safe navigation of its vessels at all times when underway, including:
-Defining the role, responsibility, training and experience necessary of a nominated navigator.
-Ensuring that thorough passage plans are prepared, taking into account guidance identified in this report.
-Ensuring that procedures include instructions when the nav station should be manned and navigation reporting policies between the nav and helm stations.
-Provision of training and guidance for all crew who may have navigation duties in the use of electronic navigational systems and how to identify hazards ahead within the determined fixing interval.
The full report is published on the MAIB website here.