The UK’s Marine Accident Investigation Branch (MAIB) has today published its final report into two fatal accidents in the 2015-16 edition of the Clipper Round the World Yacht Race, the first in the event’s 20-year history.
During the Clipper Round the World Race of 2015/16 while 122 miles west of Porto, Portugal on 4 September 2015, a crew member sustained a fatal injury during an uncontrolled gybe.
Later in the same race on 1 April 2016, an untethered crew member was washed overboard from the yacht. The crew member was recovered after one hour and 20 minutes in the water, but never regained consciousness.
Both deaths involved crew aboard the UK registered yacht CV21, IchorCoal, and occurred on 4 September 2015 and 1 April 2016.
A Clipper Race spokesman said the reasons why these individuals failed to follow their basic training in these incidents will remain unknown and theories are purely speculative.
The MAIB report highlights the following safety issues:
- Effective supervision would have provided opportunities to prevent both accidents
- Danger zones need to be clearly marked on deck
- Given the uncertainty of successful man overboard search and recovery, particularly in atrocious weather, the need to clip on is paramount
- Skippers need to be effectively supported and, where appropriate, challenged to ensure safe working practices are maintained
Steve Clinch, Chief Inspector of Marine Accidents, said: ‘While a single employee on board a commercial yacht may provide sufficient company oversight in many circumstances, the special nature of the Clipper Round the World Yacht Race places a huge responsibility on one person to ensure the safety of the yacht and its crew at all times.
‘Therefore, in addition to acknowledging the completed and ongoing actions taken following the two accidents featured in this report, I am recommending Clipper Ventures plc review and modify its onboard manning policy and shore-based management procedures so that Clipper yacht skippers are effectively supported and, where appropriate, challenged to ensure that safe working practices are maintained continuously on board. In particular, consideration should be given to the merits of manning each yacht with 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.’
Clipper Ventures plc has been recommended (2017/107) to review and modify its onboard manning policy and shore-based management procedures so that Clipper yacht skippers are effectively supported, and where appropriate, challenged to ensure safe working practices are maintained continuously on board.
A recommendation (2017/108) has also been made to Clipper Ventures plc to complete its review of the risks associated with MOB and recovery, and its development of appropriate control measures to reduce those risks to as low as reasonably practicable.
A recommendation (2017/109) has been made to the Royal Yachting Association, World Sailing and British Marine, which is intended to encourage recreational and professional yachtsmen to consider carefully the type of rope used for specific tasks on board their vessels.
A recommendation has also been made to Marlow Ropes Ltd (2017/110), the rope manufacturer, aimed at improving the information provided to users on the loss of strength caused by splices, hitches or knots when using high modulus polyethylene rope.
The publication of the MAIB report has been welcomed by Clipper Race founder and chairman, Sir Robin Knox-Johnston, who said: ‘The MAIB has an important role in ensuring that the valuable learnings from accidents are shared with the industry to help improve safety. These two fatalities, resulting from two very different incidents, were the first in our long history and are tragic, especially as they were caused primarily through momentary lapses in applying basic safety training.
‘The report acknowledges that we have been proactive to mitigate the risks concerned even further. Safety has been our highest priority since the Clipper Race was established in 1996, amassing huge experience through ten biennial editions, 84 yacht circumnavigations (a cumulative four million nautical miles) with nearly 5000 crew undergoing extensive training.
‘Manning arrangements and shore-based management have been developed to ensure skippers are adequately supported and these will continue to be regularly reviewed.
‘We have developed our current manning levels and qualifications in conjunction with the MCA (Maritime and Coastguard Agency), operating to MCA standards as a minimum and often well in excess.
‘We frequently implement and develop safety procedures where there is no actual requirement; they are under constant review as a matter of course and we will continue to do so in light of the report’s recommendations.’
The Clipper Race has worked closely with the MCA for many years in developing its safety standards and procedures, and has helped develop MOB (man overboard) and recovery training with them and the MAIB prior to these incidents, which has included the assessment of AIS (Automatic Identification System) beacons.
A minimum of at least one crew member per team is trained to qualify for a Clipper Race Coxswain Certificate, developed with, and approved by, the MCA, to support the skipper and take over in the event that they are incapacitated.
Clipper Race training is designed to ensure that amateur crew can handle the specific demands of large yacht ocean racing and even novices emerge as competent sailors. Training also includes an independently provided sea survival course recognised by the RYA (Royal Yachting Association) and World Sailing, even though it is not a requirement.
Sir Robin added: ‘We will continue our long established collaboration with the MCA and MAIB, to develop, test and improve safety standards, devices, methods and procedures, not only for the benefit of Clipper Race crew but also to pass on any lessons learned, during the toughest around-the-world race that is available to amateur crew, to the sailing community at large.’
Ocean racing is at the mercy of the elements and these can include extreme weather consisting of high winds and big seas, posing a risk of potential injury to crew and damage to yachts. Good maintenance, operating standards and procedures are used to minimise these risks and ensure that safe working practices are maintained. The Clipper Race aims is to ensure all risks are identified and managed, providing appropriate levels of safety, aboard its own matched fleet of twelve identical 70-foot yachts.
Many crew are attracted by the scale of the challenge and adverse conditions to achieve something remarkable, whether it be a single ocean crossing or an entire circumnavigation. The weather makes no exception for their status; they face the same harsh conditions as any other ocean race. Hence, professional standards are applied throughout. At more than 40,000 nautical miles, the Clipper Race is one of the world’s toughest endurance challenges.
The 11th edition of the Clipper Race will start from the UK in August this year and return in late July 2018.
Incident summaries and key points
ANDREW ASHMAN (49) – A paramedic from Orpington, Kent, was participating in three legs of the Clipper 2015-16 Race.
His death occurred on 4 September 2015, a few days into the first stage of the race from London to Rio de Janeiro in the North Atlantic approximately 120 nautical miles west of Porto, on the Portuguese coast.
Andrew Ashman, an experienced sailor who had completed the Clipper Race’s mandatory four part, four week, intensive training, stepped over the main sheet traveller, a high obstruction in the danger zone between two prominent winches, when he was hit by the mainsheet on the boom.
He sustained a high impact neck injury that is believed to have killed him instantly. This is a high-risk area taught to the crew during training because of the danger of being hit by the boom.
The MAIB report states that the cause of the unexpected and sudden movement of the yacht was the accidental gybes, during which the preventer securing strop failed. This strop had been constructed using high modulus polyethylene rope. An assessment of the preventer arrangement by Clipper had concluded that it was fit for purpose. The strengths of the preventer line, strop and pad-eye were estimated but not documented and no estimate of their expected in service loading had been recorded.
The report acknowledges that it is probably not feasible to design a preventer system that, for yachts of the size used by the Clipper Race, will not fail under any circumstances; indeed, it could be more dangerous if it did not.
However, MAIB has recommended that the Royal Yachting Association, World Sailing and British Marine work together to provide advice on the use and limitations of different rope types and for the manufacturers in this instance to review the information provided on their data sheets and to work with other rope producers to share any limitations with the marine sector for more accurate calculation of their strength and breaking strains.
A recommendation has been made to Marlow Ropes Ltd, the rope manufacturer, aimed at improving the information provided to users on the loss of strength caused by splices, hitches or knots when using high modulus polyethylene rope. A recommendation has also been made to the Royal Yachting Association, World Sailing and British Marine, which is intended to encourage recreational and professional yachtsmen to consider carefully the type of rope used for specific tasks on board their vessels.
SARAH YOUNG (40) – A company owner from London was participating in the full circumnavigation of the Clipper 2015-16 Race.
Her death happened on 1 April 2016, day 12 of the North Pacific leg from Qingdao in China to Seattle on the west coast of the US, at 39 North, 160 East, approaching the International Date Line.
Round-the-world crew member Sarah Young was on deck at night during a storm with wind speeds of more than 40 knots, gusting over 60 knots, following the reduction of sail area to respond to the adverse conditions, when a wave broke over the deck causing her to lose her footing ending up next to the guardrail when a second wave washed her overboard as she was not connected to the boat by her safety tether.
The MAIB report states: ‘It is unknown why Sarah did not attach her tether, but it could have been for one or more reasons, including: fatigue, forgetfulness or distraction. The investigation established that the tethering practice on board CV21 was inconsistent. To prevent this there needed to be a robust safety culture built on strong leadership, discipline and effective oversight.
‘Clipper’s MOB recovery procedure was well established. However, two main factors delayed the recovery of Sarah: the difficulty of lowering the headsails and the time taken to recover Sarah once on scene. Although MOB drills had been briefed on board CV21, no practical MOB drills were completed with the crew for the Race leg together, an omission in common with other Clipper yachts.’
The conditions were horrendous and by the time Sarah was located via her AIS beacon and recovered from the heavy seas she had sadly perished. Due to the long distance from landfall Sarah was buried at sea once the sea conditions had calmed sufficiently.
In adverse weather crew will perform to the best of their ability in the prevailing conditions when a ‘text-book’ procedure may simply not be practical.
The MAIB acknowledge that the Clipper Race has all these factors under constant review and recommends it should continue to minimise the risks associated with a Man Overboard (MOB) incident. Recovery will always be challenging which is why so much emphasis is placed on the use of MOB drills and safety tethers.
The MAIB have attended the Clipper Race’s frequent tests of equipment and procedures prior to these incidents.
The following aspects were highlighted in the report:
- Tethering arrangements and procedures have been developed in consultation with the MCA and MAIB and will continue to be reviewed regularly. The Clipper Race has two tethers on the special life jackets that are manufactured for each race. MAIB personnel were present for testing and acceptance of the current system.
- The Guardrail was designed to provide even greater protection than UK Government regulation requires. It is no substitute for clipping on, and would not prevent someone being thrown over the top of the guardrail. This is really a matter for the Ocean Racing Council, the International body that makes the yacht racing safety rules, to revise the standard if they think it appropriate.
- AIS beacon carriage is not currently a requirement in any race, however the Clipper Race was the first to put AIS beacons on Dan Buoys, which are thrown into the sea to mark the position of a person who has fallen overside and will track their movement in the prevailing wind and currents. A number of beacons have been trialled for reliability. The issue of it becoming a requirement is a matter for the RYA, World Sailing and the MCA to comment. In Sarah’s case she wore a personal AIS beacon which had to be manually activated.
- Sea Survival Training is not actually a requirement. The Clipper Race includes a course run by external providers which incorporates the demonstration of spray hoods as part of the syllabus. The courses used are those approved by the MCA, RYA and World Sailing. Health and safety considerations implemented by the providers restrict the level of ‘realism’ in terms of clothing and pool temperatures, but still provide a very valuable insight and practice for crew. The Clipper Race will review further with the providers but it should be noted that the same course is used by professional fishermen, an industry which has suffered 94 fatalities in the last 10 years, 526 people seriously injured, with some 200 boats lost.
- MOB Recovery Training is provided extensively during pre-race training and throughout the race. Each boat is equipped with a 75KG dummy for MOB and recovery drills following development trials attended by the MAIB. The crew experience a wide range of weather conditions during their training and on the race, so they know what to expect, but there comes a point where it is not safe to run a drill in very adverse conditions.
- Sail Plan Arrangements used by the Clipper Race, using piston stay hanks, are regarded as the safest and most reliable method. Adverse conditions hamper bringing sails down in any arrangement.
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