d***@gmail.com
2012-11-02 02:14:44 UTC
3.0 Conclusions
3.1 Findings as to Causes and Contributing Factors
1. When the master handed over the watch to the second officer (2/O), he did not provide
instructions that would have allowed the 2/O to react to changing weather conditions
appropriately and maintain the stability of the vessel.
2. Despite the changes in the wind conditions in the 60 to 75 minutes preceding the occurrence
and the fact that several squalls were being tracked, both visually and on the radar, the 2/O
did not perceive any threat to the vessel.
3. As the apparent wind speed increased with the onset of the squall, the vessel’s heel angle
reached roughly 23. for approximately 2 to 3 minutes without mitigating action being taken.
4. In response to a further, modest increase in wind speed, probably including a vertical
component, the vessel began to heel beyond 23.. At this point, the action taken to steer
downwind was too late to prevent the vessel from heeling to angles sufficient to immerse
the lee-side doors and ventilators.
5. The forward and aft deckhouses had not been fully secured weathertight and, therefore, the
vessel’s righting ability at large angles was reduced and protection against the ingress of
water was compromised. As a result, downflooding progressed until the vessel lost all
stability and capsized.
6. Concordia’s shore-based management did not provide direction on the need for squall tactics
and stability booklet familiarization, which would have provided an additional defence
against a knockdown and capsize.
3.2 Findings as to Risk
1. In the absence of guidance information that addresses a sailing vessel’s stability in terms of
the sail plan and environmental conditions under which it is operating, officers may lack
key information with which to assess the corresponding risk to safety.
2. In the absence of training, sailing vessel masters and officers may not be able to interpret
and make effective use of the critical guidance information provided by stability booklets.
3. The complement of a sailing vessel is placed at increased risk when emergency
preparedness and response to knockdown scenarios are not given specific consideration.
4. Officers must be familiar with the autopilot settings and be able to recognize navigational
situations when steering by autopilot is undesirable in order to avoid placing the vessel at
unnecessary risk.
5. Emergency Position Indicating Radio Beacon (EPIRB) registration information that is
inaccurate or incomplete is likely to delay search and rescue efforts.
6. By not immediately notifying area vessels of a distress, search and rescue resources may
miss opportunities to effect a timely rescue, which is critical to the survival of those in
distress.
7. By not making the fullest use of equipment that is designed to assist search and rescue
authorities, the chances of discovery and rescue are reduced.
8. Where they offer no improved chances for survival, helicopter transfers can expose those
involved to unnecessary risks.
9. In the absence of requirements for effective safety management systems, there is an
increased possibility that individuals at all levels of an organization may not have the
appropriate knowledge and tools to effectively manage risk or the necessary information to
make sound decisions in any operating condition.
10. Delays in search efforts prolong the hardship of survivors (and their loved ones) and
increases the risk of harm after a vessel abandonment.
3.3 Other Findings
1. The wind speeds experienced by the vessel at the time of the knockdown were most likely
in the range of 25 to 50 knots. While there was probably a vertical component to the wind,
there is no evidence that a microburst occurred at the time of the knockdown.
2. Some large sailing vessels may have a combination of sail plan and stability characteristics
that can make them vulnerable to wind speeds below 30 knots.
3. Conditions in the rafts were made more difficult by the lack of stowage for emergency
equipment and problems with the bailers, foot pumps and flashlights.
Bardzo wazne jest zeby kapitanowie i oficerowie duzych zaglowcow zdawali sobie sprawe z tego jak duzy przechyl moze juz zagrazac bezpieczenstwu. Mimo wszystko jednak umieszczenie wymogu dobrej znajomosci poslugiwania sie autopilotem dopiero w drugiej kategorii zagrozenia i to nawet nie na pierwszym miejscu jest moim zdaniem niepowazne. Gdyby na tym zaglowcu nie bylo autopilota tylko sternik za kolem sterowym, to moim skromnym zdaniem do katastrofy by nie doszlo. Zaglowiec napewno nie posuwalby sie niebezpiecznym kursem przez kilka minut zanim ktos by zaczal reagowac. Co wiecej, sternik mialby duze trudnosci z utrzymaniem kursu i jest duza szansa ze w pewnym momencie by tego kola nie utrzymal, a jacht sam by w tym momencie odpadl.
anonim ciekaw opinii bardziej doswiadczonych zeglarzy
3.1 Findings as to Causes and Contributing Factors
1. When the master handed over the watch to the second officer (2/O), he did not provide
instructions that would have allowed the 2/O to react to changing weather conditions
appropriately and maintain the stability of the vessel.
2. Despite the changes in the wind conditions in the 60 to 75 minutes preceding the occurrence
and the fact that several squalls were being tracked, both visually and on the radar, the 2/O
did not perceive any threat to the vessel.
3. As the apparent wind speed increased with the onset of the squall, the vessel’s heel angle
reached roughly 23. for approximately 2 to 3 minutes without mitigating action being taken.
4. In response to a further, modest increase in wind speed, probably including a vertical
component, the vessel began to heel beyond 23.. At this point, the action taken to steer
downwind was too late to prevent the vessel from heeling to angles sufficient to immerse
the lee-side doors and ventilators.
5. The forward and aft deckhouses had not been fully secured weathertight and, therefore, the
vessel’s righting ability at large angles was reduced and protection against the ingress of
water was compromised. As a result, downflooding progressed until the vessel lost all
stability and capsized.
6. Concordia’s shore-based management did not provide direction on the need for squall tactics
and stability booklet familiarization, which would have provided an additional defence
against a knockdown and capsize.
3.2 Findings as to Risk
1. In the absence of guidance information that addresses a sailing vessel’s stability in terms of
the sail plan and environmental conditions under which it is operating, officers may lack
key information with which to assess the corresponding risk to safety.
2. In the absence of training, sailing vessel masters and officers may not be able to interpret
and make effective use of the critical guidance information provided by stability booklets.
3. The complement of a sailing vessel is placed at increased risk when emergency
preparedness and response to knockdown scenarios are not given specific consideration.
4. Officers must be familiar with the autopilot settings and be able to recognize navigational
situations when steering by autopilot is undesirable in order to avoid placing the vessel at
unnecessary risk.
5. Emergency Position Indicating Radio Beacon (EPIRB) registration information that is
inaccurate or incomplete is likely to delay search and rescue efforts.
6. By not immediately notifying area vessels of a distress, search and rescue resources may
miss opportunities to effect a timely rescue, which is critical to the survival of those in
distress.
7. By not making the fullest use of equipment that is designed to assist search and rescue
authorities, the chances of discovery and rescue are reduced.
8. Where they offer no improved chances for survival, helicopter transfers can expose those
involved to unnecessary risks.
9. In the absence of requirements for effective safety management systems, there is an
increased possibility that individuals at all levels of an organization may not have the
appropriate knowledge and tools to effectively manage risk or the necessary information to
make sound decisions in any operating condition.
10. Delays in search efforts prolong the hardship of survivors (and their loved ones) and
increases the risk of harm after a vessel abandonment.
3.3 Other Findings
1. The wind speeds experienced by the vessel at the time of the knockdown were most likely
in the range of 25 to 50 knots. While there was probably a vertical component to the wind,
there is no evidence that a microburst occurred at the time of the knockdown.
2. Some large sailing vessels may have a combination of sail plan and stability characteristics
that can make them vulnerable to wind speeds below 30 knots.
3. Conditions in the rafts were made more difficult by the lack of stowage for emergency
equipment and problems with the bailers, foot pumps and flashlights.
Bardzo wazne jest zeby kapitanowie i oficerowie duzych zaglowcow zdawali sobie sprawe z tego jak duzy przechyl moze juz zagrazac bezpieczenstwu. Mimo wszystko jednak umieszczenie wymogu dobrej znajomosci poslugiwania sie autopilotem dopiero w drugiej kategorii zagrozenia i to nawet nie na pierwszym miejscu jest moim zdaniem niepowazne. Gdyby na tym zaglowcu nie bylo autopilota tylko sternik za kolem sterowym, to moim skromnym zdaniem do katastrofy by nie doszlo. Zaglowiec napewno nie posuwalby sie niebezpiecznym kursem przez kilka minut zanim ktos by zaczal reagowac. Co wiecej, sternik mialby duze trudnosci z utrzymaniem kursu i jest duza szansa ze w pewnym momencie by tego kola nie utrzymal, a jacht sam by w tym momencie odpadl.
anonim ciekaw opinii bardziej doswiadczonych zeglarzy