In the 2015-16 Clipper Around the World Race, two people died. One crew member was struck by the mainsheet and had his neck broken during an uncontrolled gybe and the second was washed overboard in poor conditions at night, tragically it took 80 minutes to recover her despite having an AIS transponder on her person. Both deaths were preventable.
Pay to Play
The RYA has close ties to the Clipper Around the World Race with the current Training Manager and Chief Examiner Richard Falk having skippered Uniquely Singapore in the 2005-2006 race. The brainchild of renowned solo sailor and TV personality Robin Knox-Johnston, the Clipper race is unique for taking everyday people and putting them into a harsh environment and testing them to their limits. Prior to joining the race, crew members undergo a training/selection process with a heavy focus on safety. The training portion, which is mandatory, will set the applicant back almost $10,000, a full circumnavigation costs $100,000. Believe it or not they pay for the privilege of risking their lives.
To his credit, Knox-Johnston has supported the resulting MAIB investigation and published a summary of the final report front and centre on the Clipper website (the full report can be found here). Knox-Johnston clearly attributes the deaths to a failure of both individuals to observe basic safety training. The MAIB report paints a different story.
How to Break a Neck
Andrew Ashman was 49, active and a paramedic in real-life. In worsening conditions off the coast of Portugal, just before midnight, the gybe preventer snapped and the boom fired across the cockpit in one direction before another uncontrolled gybe sent it back again. In a classic case of being in the wrong place at the wrong time, Andrew Ashman, for whatever reason, found himself in the ‘danger zone’ during the gybes – a fatal turn of events.
Clear takeaways from the MAIB report highlight two important aspects of safety on sailing vessels: decision making and equipment failure.
Sailing instructors are fond of the axiom that one bad decision begets another. In this case the MAIB report states that “At 2330, the helm was passed to one of the least experienced helmsmen…“, which happened concurrently with the wind building to 30 knot gusts. While everyone values their time at the helm, hurtling downwind in a 70ft racing boat is not the best time to build experience, it’s the time you need experience. While this decision alone didn’t end Andrew’s life it was probably the most significant – importantly, it was Andrew, a newly minted ‘watch leader’ who made the decision to leave the inexperienced helmsman at the wheel.
Where was the skipper while things were going wrong? He was down below getting some well-deserved rest. The Clipper boats operate with one professional skipper, typically they are a Yachtmaster Ocean, typically they are an Instructor as well. His job is to look after the 21 crew members on board. It’s a tough job. To put the task in perspective, the RYA has a Student/Instructor ratio of 5:1, which is both manageable and safe. Delivery skippers usually operate with 2 or 3 crew. But having 21 amateurs packed into a floating sardine can which moves at 20 knots requires some serious babysitting skills.
There’s no question Clipper Ventures does a good job of training their skippers for the race, but the MAIB is clearly of the opinion that even with all the training there needs to be at least one more professional on the job. They’re right. With the wind and sea building, Andrew sought the skipper’s permission to reef the sails, which was given. In truth, the decision should have come earlier and it should have come from the skipper himself. Further, the MAIB states the skipper’s decision to remain below and let Andrew get on with it, “… resulted in the deck being left unsupervised by him at a time of heightened risk.” It was in the process of explaining to the deck crew the reefing process that Andrew inadvertently entered the ‘danger zone’, the gybe happening so quickly he was probably unaware of his mistake. Andrew was a Day Skipper.
The gybe need not have been so fatal if the gybe preventer had held. Reading between the lines it’s clear the Clipper Race has had problems with accidental gybes before, which is why they had come up with a new preventer system before the race. The mistake here was simple – there was no scientific testing of the dyneema strop systems load tolerance in that configuration. It was a bit of a thumb-suck job really, albeit by a professional rigger – it happens a lot on boats. Equipment failure, under these circumstances, could have been avoided with a bit more foresight and science. if not that, then having a secondary preventer rigged may have done the job, especially as the Clipper’s own standard operating procedures state “… the skipper is advised to rig a second temporary preventer when the course they are on is likely to be steady for a considerable time.” Why it wasn’t rigged isn’t addressed in the report.
Bang on the Head
13ºC is a good water temperature if you’re a polar bear, not a human. Of the many remarkable aspects surrounding Sarah Young’s death, the fact she was able to stay alive for so long in such cold water is a testament to her physical fitness and will to live. But, like Andrew, it was Sarah’s decision making which let her down.
There are two types of safety: preventative and reactive. Good instructors and skippers will focus more on the former than the latter. Lifejackets are great bits of kit with lots of bells and whistles (one whistle anyway) BUT it is the oft overlooked and unsexy D-Ring which is critical. Attaching a tether to the D-Ring and then to a jackstay or secure point on the boat renders all the sexy bits immaterial – if you never leave the boat then you won’t need to use them. ‘Clipping on‘ is rule number one in adverse conditions when up on deck. The MAIB is unequivocal in identifying Sarah’s failure to clip on as the most important factor in her subsequent death.
While it’s hard to say why she didn’t clip-on under the circumstances (40kts gusting 60kts) the MAIB does point to a rather lackadaisical attitude towards the use of tethers as being an issue on board. The fact she was in the companionway trying to help secure a winch handle pocket may just mean she felt safe there, especially in light of the fact she had been clipped-on earlier when reefing the mainsail in a far more vulnerable location. She could just have been tired and it slipped her mind. Either way she was washed out of the cockpit by the first wave crashing over the port side and washed overboard by the second wave. The guardrails were ineffective.
In 2007 the iconic Canadian tall ship, the Picton Castle, lost Laura Gainey, the daughter of Hockey Hall of Famer Bob Gainey, overboard when a wave swept the deck and took her to Davy jones locker. The subsequent independent report was scathing in its assessment of the Picton Castle’s safety standards. Of the numerous issues identified some are applicable to the Clipper tragedy: fatigue, failure to be tethered to the vessel, too few “…certified, professional deckhands on board“, and no netting to prevent people being washed overboard. Netting might have saved the day.
Being washed overboard in the middle of the night must have been terrifying. No amount of training in a warm swimming pool counts as preparation for being plunged into cold stormy waters in the dark. Good things did happen though, her lifejacket inflated and her AIS transponder worked. If she was able to throttle the panic then hopefully she would remember her training and focus on conserving her body heat. If she believed in her skipper, as she should, then it would just be a matter of time until he comes back to get her. And he did, it just took too long.
It says a lot about the conditions that the skipper was unable to maneuver the boat with any authority with the engine on. It took from 2324 (Man Overboard) to 2356, 32 minutes for the skipper and crew to gain the necessary maneuverability in order to begin their first approach towards Sarah, by now a distance of 2 nautical miles (almost 5km). The delay is attributed to the length of time it took to bring down both headsails. This is almost entirely due to the inexperience of the crew and the conditions.
The Clipper MOB protocols are sound, but like so many things in this world theory and practice are often miles apart. The skipper is a soft target here but the the truth is he was probably working at the physical and mental limits of his abilities. Should he have gone forward to assist or was he more valuable on the helm? Head to wind or downwind in order to get the sails down? All the time with this internal clock ticking away and the stomach churning thought it was taking too long and they were moving too far away.
His relief in locating Sarah and knowing she was conscious must have been palpable, he was in with a chance. All that remained was to pluck her out of the water.
Watching Yachtmaster candidates lose their composure while trying to effect an MOB in fine conditions during their practical exam is telling about the effects of pressure. The repeated attempts to get close to Sarah and get her out of the water must have taken their toll on the skipper. From first approach to getting her on deck took 30 minutes and in those 30 minutes Sarah went from conscious to unconscious. The comedy of errors involved an improperly secured halyard and a rescue swimmer almost becoming the second casualty of the night. No scramble net was deployed.
Because Sarah was later buried at sea (the Clipper boats have no suitable cold storage to keep fatalities) it’s difficult to ascertain what was the exact cause of death. The MAIB makes note of the fact two lumps, one bleeding, were found on Sarah’s head during the post mortem carried out by the medic on board, raising the possibility she may in fact have been killed during the recovery attempt.
Pictures of Sarah available on the internet show her wearing a helmet (presumably for working on the foredeck). The MAIB report makes no mention of helmets BUT, just to add an observation, wearing one in adverse conditions may just prevent a bump on the head, either on or off the boat.
The Blame Game
Yes, Knox-Johnston is correct in identifying “…momentary lapses in applying basic safety training” as contributing to the death of both Andrew and Sarah. It’s an obvious and convenient conclusion for the race organisers. Clipper Ventures plc is, after all, a business. But does it do justice to the MAIB report?
The answer is more complicated. There’s no question, echoing the Picton Castle report, the MAIB believes Clipper Ventures needs “…a second employee or contracted ‘seafarer’ with appropriate competence and a duty to take reasonable care for the health and safety of other persons on board.” And they are right. A second skipper/first mate with similar qualifications and experience is a good solution. It reduces the fatigue factor and it adds a second (qualified) opinion when it’s needed. It means more supervision on deck where a seasoned skipper/instructor may have been able to alert Andrew to his error or shout at Sarah to clip-on. It would almost certainly have meant bringing the headsails down a lot quicker. It’s clear that Clipper Ventures is more invested in giving that responsibility to graduates of their Coxswain course (Andrew passed the course) as it saves the expense of having a second skipper on hand. It’s a classic case of safety vs business, risk vs reward. It would be interesting to hear what the skipper himself thinks, because in the end it’s down to him.
Here are other important lessons:
- There is no such thing as reefing too early. A failure to reef early was a factor in both accidents.
- Fear the Gybe. Fear is healthy.
- Equipment failure is a reality of life on boats. Have a plan B.
- Things don’t go wrong at 3 in the afternoon on a calm day. Both accidents took place around midnight in harsh conditions. Train for that.
- AIS works.
- Safety gear is only useful if you use it. Sarah’s helmet and drysuit were on the boat.
- Buy a lifejacket with a spray-hood – use it.
- Winch handles can be replaced, people can’t. Sarah wen’t into the water hanging onto a winch handle instead of grabbing for a fixed point on the boat. Is it because it was drummed into her not to lose a winch handle overboard? Hmmm… Instructors know what this means.
- Never give up. Well done Sarah.
The Clipper Race is well run and run by some great sailing people. It’s fair to assume they took the loss of Alan and Sarah pretty hard. Hopefully corporate culture and the fear of litigation won’t stop them from having a good hard look at their already strong safety procedures, especially when it comes to MOB’s in heavy conditions.
My final thought has to do with experience. It’s a cliché to say there’s no substitute for experience but it’s true and nowhere more so than out at sea.