rachel harvey
Contents
1. Signature Wheelhouse and Galley Extract from risk assessment Standard Risk Assessment Form WHEELHOUSE AND GALLEY Leaving wheelhouse Vessel loss deaths watchkeeper at the time of the accident had served aboard Rachel Harvey for six months and had kept a watch on fishing vessels numerous times during several years at sea Due to the way she was operated the safety of navigation and passage watchkeeping on Rachel Harvey relied largely on the proper operation of the GPS autopilot interface and on the ability of the skipper and watchkeepers to monitor it To monitor it a watchkeeper needs a thorough understanding of the indicated cross track error information and the ability to take and plot positions on the chart To be able to do this adequately the watchkeepers needed some fundamental navigational knowledge and specific training and instructions regarding the GPS autopilot interface F2 had undertaken a Youth Training Scheme course on entry to the industry but this had not included any substantial watchkeeping or navigational training His navigational experience had been gained over about six and a half years at sea on fishing vessels During the investigation it became apparent that F2 could not plot a position on a chart given its latitude and longitude and he could not interpret the scale of a chart The only instruction he had received on the2. The wheelhouse was well equipped with modern instrumentation 1 6 The vessel s intended course was not plotted on the chart nor on the video recorder Rachel Harvey was correctly fitted with the safety equipment required by law 1 7 20 18 19 20 21 22 22 23 24 25 26 27 28 29 3 2 221 Distress messages were transmitted in three ways by DSC by radio on cbannel 16 and by EPIRB The coastguard received all transmissions 2 7 2 Only those of the crew who were considered competent by the skipper were permitted to keep a navigational watch 1 9 The track control system was used extensively by the skipper when the vessel was on passage 1 9 There is no evidence to suggest fatigue drugs or alcohol were factors in the accident 1 11 Neither the owner nor the skipper kept proper records concerning the crew s qualifications and training 2 2 If Andrew Dyson had undertaken the course in basic survival at sea it may have saved his life 2 2 F2 had neither enough fundamental knowledge nor sufficient training to keep a safe navigational watch on Rachel Harvey 2 3 Because it was impossible to recover information from Rache Harvey s instruments to substantiate the witness evidence many of the factors which led to the grounding will never be known 2 4 The Navitron autopilot s operations manual was found to be poorly laid out and difficult to understand 2
3. 17 Findings New navigational instruments were fitted to Rachel Harvey in December 1998 1 1 Rachel Harvey had been laid up in Newlyn for five days prior to the accident due to a lack of crew 1 1 Rachel Harvey had left Newlyn in the late morning of the day of the accident She had then hauled rebaited and shot about 600 pots during the afternoon before starting a passage to St Mary s at 1900 1 2 The skipper set up and made sure that the track control system was operating before handing over to the first watchkeeper 1 2 F2 took over the watch at about 2010 1 2 F2 monitored the navigation by observing the radars 1 2 The vessel was yawing in the moderate to rough sea conditions The south westerly wind of force 7 was on the port bow The visibility was poor in rain showers 1 2 F2 tried to alter the vessel s heading by turning the course setter knob on the autopilot 1 2 Rachel Harvey grounded at the extremity of Peninnis Head 1 2 The vessel sank within two to three minutes of the grounding 1 2 All of the surviving crew were able to get off the vessel and all but one had lifejackets 1 2 Only one of the crew was able to board the liferaft the others were carried away by the tidal stream 1 2 Some of the crew had not undergone training in sea survival fire fighting and first aid 1 3 1 4 The owners had started to carry out risk assessments for the operation of the vessels in their fleet 1 5
4. 4 The tubular steel framework which surrounded the after deck impeded the escape of crew members as the vessel was sinking 2 7 1 To the skipper s credit distress messages were transmitted successfully by three different methods 2 7 2 Initially the liferaft remained attached to the vessel while the crew in the water were swept away by the tide 2 7 3 The crew did not activate their lifejacket lights 2 7 4 Causes The Immediate Cause The cause of the grounding cannot be established beyond doubt due to a lack of substantive evidence However in broad terms the grounding occurred due to poor navigational management and an over reliance on the automatic track control system 2 4 2 5 21 322 Underlying Causes The watchkeeper lacked training in the operation of the bridge equipment 2 3 The watchkeeper did not know the vessel was being controlled by a track control system 2 3 The watchkeeper lacked the fundamental knowledge necessary to navigate safely 2 3 The skipper did not ensure that all his watchkeepers knew and understood the vessel s navigational equipment 1 10 2 2 2 3 The skipper relied too heavily on the track control system to keep the vessel in safe water 2 5 The skipper did not ensure that all the watchkeepers were competent to keep a safe navigational watch 2 3 22 SECTION 4 RECOMMENDATIONS On 10 November 1999 the MAIB issued Safety Bulletin 3 99 which included the fo
5. and turn the light off the pin would then have been replaced Rachel Harvey was fitted with a DSC radio which in the event of an emergency would when activated automatically transmit the name of the vessel and her position The vessel was also equipped with an EPIRB which was designed to float free automatically if the vessel foundered and then transmit a distress message Rachel Harvey s EPIRB operated on both the 406MHz and 121 5MHz frequencies The DSC radio and the EPIRB were both parts of the GMDSS 1 8 Heading and Track Control System The Navitron NT 921 autopilot fitted to Rachel Harvey was interfaced with one of the vessel s GPS receivers Cross track error information derived from the GPS receiver was passed electronically to the autopilot which made appropriate heading alterations to bring the vessel back on the planned track The main functions of the instrument controls are as follows photograph 1 e When the vessel is being hand steered the Autopilot Mode switch must be turned to either the stand by or the off position e When off is selected the instrument is disconnected e Inthe stand by mode the central dial acts as a compass repeater indicating the ship s head and following any variation caused by helm movements or outside influences Turning the central knob in this mode has no permanent effect on the dial or indicated heading Mode switch must be turned to fo
6. decided to maintain her Jersey registration She was renamed Rachel Harvey in 1998 In December that year new navigational instruments were fitted including an autopilot with an interfaced track control system Rachel Harvey was a specialist potting vessel She operated 15 strings each of 100 pots which were generally laid in the area of the traffic separation zone between Land s End and the Isles of Scilly Figure 1 chart extract Her catch of crabs was intended mainly for the French market A typical voyage of five or six days was preceded by a day or two of leave for the crew of six while the vessel was laid up in Newlyn After preparations for sea were completed including loading bait and other stores Rachel Harvey departed and made passage of about three hours directly to the fishing grounds During the next four or five days the crew hauled rebaited and daily shot about 1000 pots The catch was stored and kept alive on board in Vivier tanks During fishing operations the skipper navigated and manoeuvred the boat from the wheelhouse while the other five crew handled the pots The separate roles involved in handling the pots and the catch were shared on a rotational basis by the five crew each of whom shared equal status on board The skipper generally chose to moor the vessel alongside in Hugh Town St Mary s Isles of Scilly each night The passage to Hugh Town from the fishing grounds was nearly always made through St Mary s Sound alth
7. had his lifejacket on but he could feel his rigger boots pulling him down so he kicked them off When Rachel Harvey sank her Electronic Position Indicating Radio Beacon EPIRB released automatically and transmitted a distress message correctly The St Mary s lifeboat arrived 30 to 40 minutes later The lifeboat crew saw the liferaft and as the lifeboat approached F4 used four hand held flares which he found easier to set off than the rocket flares He threw the quoit as the lifeboat came close the quoit and line were easy to find as they were right by the door F4 was picked up by the lifeboat and he indicated to the lifeboat crew that others were in the water towards the east north east The searchlights on the lifeboat were used and the retro reflective tape on the other survivors lifejackets reflected the light well The crew had not activated their lifejacket lights F2 was located and picked up followed by the group of three Andrew Dyson was later found near Gilstone rocks face down with his arms spread out He had a lifejacket over his head but it was not tied around his waist The lifeboat crew tried to resuscitate him as they returned to St Mary s When they reached the quayside at Hugh Town an ambulance crew and a doctor took over the resuscitation but it was unsuccessful The lifeboat returned to the scene of the accident and recovered the liferaft and the EPIRB which by then had drifted to a position near Newfoundland Po
8. hi settings dictate the frequency with which cross track error information is acted upon Generally the lo setting should be chosen for longer passages in unconfined waters where it is unnecessary to correct the cross track error quickly The factory set amount for the lo setting is one minute but this could be adjusted by the user to be as high as three minutes resolution permits interrogation intervals of between 50 and 15 seconds e When cross track error is initially identified the track control system applies a heading correction of 5 If cross track error is still found to be increasing when next sampled a further 3 of heading correction is applied and so on until the vessel begins to move back towards the required track When the cross track error is found to be decreasing the applied heading correction begins to be reversed until the vessel is back on track and making good the correct course e Ifthe course setter control knob is turned when Radionav Interface is on either lo or hi settings the autopilot will alter the course as instructed As the induced cross track error is discovered and communicated to the autopilot the heading will be gradually altered back towards that required to maintain the planned track The actual track of the vessel will be temporarily offset from the planned track To enable cross track error to be calculated the co ordinates of the planned track need to be entered i
9. main engine exhaust The crew had only about 20 to 30 seconds to release it before the vessel sank They were unsuccessful It was dark and the senhouse slip which secured the raft to its cradle could not be seen clearly enough to be released The three crew left the vessel from the podium as she sank under them When F3 left the cabin the water was around his feet Andrew Dyson was rummaging in his bag so F3 warned him to hurry up F3 got as far as the main deck and just got out of the opening in the rails on the starboard side before Rachel Harvey sank As Andrew Dyson was coming up the stairs he was observed by F3 This was the last time he was seen alive Rachel Harvey sank 2 to 3 minutes after grounding Between 30 and 60 seconds later the liferaft came to the surface and inflated the right way up It was still attached to the vessel Initially FA was dragged by the current away from the liferaft but he grabbed hold of the sea anchor rope which he used to pull himself to the raft He heard gas escaping from a valve which he thought was a leak so tried to stop it with his hand However this was normal the valve was venting to prevent over pressure When the valve stopped venting he turned the liferaft around and found the canopy entrance He had no difficulty in boarding the liferaft The light inside was not working so he bent the canopy momentarily to shine the external light inside F4 found containers inside the liferaft He was
10. risk assessment had been completed for Rachel Harvey s operation at the time of the accident and as the vessel was Jersey registered there was no requirement for one 16 Vessel General Description Rachel Harvey was a wooden hulled vessel of 16 25m registered length She had a wheelhouse situated aft of mid length abaft which a platform podium was provided for storing empty pots and other equipment To aid the security of the equipment which was sometimes stowed on the podium and on the small after deck beneath a tubular steel framework had been constructed photograph 2 The sleeping accommodation for the six crew was situated beneath the main deck aft of the wheelhouse A ladder from the cabin led up to the galley area which was immediately aft of the wheelhouse A door from the galley led directly to the wheelhouse photograph 3 Another door led aft on to the after deck The wheelhouse was well equipped with modern instrumentation much of which had been newly fitted about nine months before the accident The wheelhouse equipment included Two radars Furuno M1942 and Furuno M1940 Video plotter Furuno GD188 Two GPS navigators Furuno GP70 Mk 2 Furuno GPS 1GP50 Echo sounder Furuno FCV271 Searchlight Francis 11 inch Autopilot Navitron NT 921 with interlocked watch alarm VHF radio Furuno Radio Furuno FS1550 SSB EPIRB Jotron 305 with Hammer HRU wheelhouse chair was sited
11. this case the skipper Once altered from the factory settings the effects of the different settings are not known precisely For the reasons outlined above it is impossible to say what effect the settings that were found on Rachel Harvey s recovered autopilot would have had on her track keeping ability photograph 1 If the factory settings had remained unaltered the following would have applied Rudder 1 a half a degree of helm would be applied for every degree of heading alteration required Yaw maximum sensitivity to heading offsets mean headings sampled to determine helm to be applied e Autopilot on all functions of the autopilot active including permanent helm to overcome effects of wind on the bow Radionav Interface cross track error sampled every 60 seconds 16 The setting on the yaw control would have caused unnecessary rudder movement It was set incorrectly for the fairly rough sea conditions that prevailed The rudder control setting was very low and could have seriously affected the vessel s ability to maintain her track Strong wind and tide were acting on the port bow and forcing the vessel off track to the north 12 of helm for every 1 of heading offset may not have been enough to overcome these forces That the interface was set on low resolution lo meant the unit would have been slow to detect the growing cross track error and it would have also been hampered by
12. GPS autopilot interface was during his first voyage on Rachel Harvey when one of the experienced crew had told him how it worked He had never previously sailed with a track control system After the accident he was aware of the existence of something called an interface but he did not know what it did He believed that to make small alterations of course when the autopilot selector switch was he needed to turn the course selector knob to the required course setting If a larger alteration of course was needed he thought that he must turn the autopilot selector switch to off or stand by and then use the course selector knob He knew there was a jogger tiller and a wheel but he had never used either However he had successfully kept the watch on board on numerous occasions and was confident in his ability to do so He had altered course successfully a number of times during passages to and from France for collision avoidance and had apparently steered the vessel past the waypoint into St Mary s Sound on previous passages using the methods outlined above As has been explained in an earlier section turning the course selector knob when the instrument is in stand by mode has no effect on the steering Turning the knob when the interface is selected and the autopilot is will have a temporary effect which will in time be counteracted by the instrument It is conceivable that a successful alteration of course for co
13. Report on the investigation of the Grounding and Loss of the Fishing Vessel RACHEL HARVEY Peninnis Head Isles of Scilly on 1 October 1999 with one fatality FILE 1 6 111 Marine Accident Investigation Branch Carlton House Carlton Place Southampton 5015 2DZ Report No 23 2000 Extract from Merchant Shipping Accident Reporting and Investigation Regulations 1999 The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future It is not the purpose to apportion liability nor except so far as is necessary to achieve the fundamental purpose to apportion blame CONTENTS GLOSSARY OF ACRONYMS AND ABBREVIATIONS SYNOPSIS VESSEL AND ACCIDENT INFORMATION SECTION 1 FACTUAL INFORMATION 11 12 13 1 4 1 5 1 6 17 1 8 1 9 Background to the Accident Narrative of Events The Crew Safety Training The Owner Risk Assessment The Vessel General Description Safety Equipment The Heading and Track Control System Bridge Watchkeeping and Navigation 1 10 The Grounding 1 11 Fatigue Drugs and Alcohol SECTION 2 ANALYSIS 2 1 22 23 24 2 5 2 6 21 Risk Assessment Crew Training Watchkeeper Competence Hypotheses on the Track Control System s Apparent Failure to Maintain the Required Track The Cause of the Grounding Fatigue Th
14. able to locate the torch which he used to examine the other contents he did not think the torchlight was particularly bright He found silver packages containing food which he put to one side and a paddle which he used to try to move the raft towards the others He could hear their shouts He made no appreciable headway and was unaware that the liferaft was still attached to the vessel He then searched for the flares which he found with some difficulty and fired off five rockets He found the triggers for the rocket flares difficult to use with cold hands F1 tried to swim to the liferaft but made no significant headway towards it against the current He could see the external light on the liferaft He thought about swimming to the shore but heard the waves breaking against the rocks and thought it would be too dangerous The skipper was the water with no lifejacket Fortunately gas bottle surfaced beside him which he clung to The bottle was the spare 19kg propane cylinder which although full still floated Little else rose to the surface The skipper 1 and F3 were shouting to each other and subsequently managed to get together in a group F1 and F3 were able to support the skipper with their lifejackets even though F3 did not have his donned properly he was only holding it They saw the rockets set off by F4 and were aware of the blue flashing lights of emergency vehicles near Peninnis Head they knew help was on the way F2
15. ast voyage all but Andrew Dyson had at some stage in their careers attended a survival course W Harvey and Sons Ltd regularly arranges for new crew members to attend the statutory safety courses However it only does this once a person has proved himself to be a valuable and reliable member of the crew In that case the company will pay the requisite course fees and regain the money later from the crew member s wages Andrew Dyson had not served on Rachel Harvey for long enough to put him into this category W Harvey and Sons Ltd did not keep an accurate record of which of its employees had undergone statutory safety training it considered this to be a matter for its skippers However Rachel Harvey s skipper believed it to be a matter for the owner A total of 21 people had sailed on Rachel Harvey during her last season of fishing New crew members were frequently required and it was not unusual for W Harvey and Sons Ltd under these circumstances to employ people who had been made unemployed from other industries with little or no experience of fishing The regulations of the States of Jersey differ from those of the UK in that they do not require each fisherman to have undergone safety training However it would have been reasonable to expect a UK based company which owns a number of fishing vessels to have ensured all its employees were trained in the three basic safety disciplines of survival first aid and fire fighting Neither the owner
16. board and saw breaking waves and rocks a few seconds later the vessel was felt to judder as she grounded The skipper and F4 had jumped out of their bunks The skipper went to the wheelhouse and pulled the engine controls back Looking out of the windows he saw waves breaking over the bows He lifted the engine room hatch in the wheelhouse saw water in the engine room and called for his shoes so that he could go down into the space to pump the water out However on looking of the window again he realised Rachel Harvey was sinking He cancelled his request for shoes and told the crew to get their lifejackets F1 F2 and F4 went down into the cabin to fetch their lifejackets and to ensure that Andrew Dyson and F3 were awake The skipper activated an automatic distress message using digital selective calling DSC on the main radio and declared on VHF radio Channel 16 The time was 2046 gave the position of the vessel which he repeated at the request of the coastguard He did this quickly and then said he was abandoning ship The skipper left by the wheelhouse door and jumped over the rails on the starboard side forward He left as the vessel was sinking and did not have time to collect his lifejacket F1 F2 and F4 had gone up to the podium after retrieving their lifejackets from the cabin On the podium which had no fishing equipment on it F1 tried to release the liferaft It was covered in soot from the
17. but was unsuccessful as he was unable to swim faster than the tide The liferaft broke away from the wreck possibly when the lifeboat came alongside to rescue F4 The internal light in the liferaft did not come on automatically this is the only item of safety equipment that did not function correctly F4 used initiative and bent the canopy so the external light shone inside He was then able to find the torch The liferaft manufacturer is investigating the operation of the liferaft internal light 18 2 7 4 flares were used to good effect The fact that the liferaft stowage position had been sited in line with the main engine exhaust outlet was a poor design feature which was a factor in the crew s inability to quickly release it Lifejackets The lights on the lifejackets did not illuminate because the crew did not activate them The Fishing Vessels Safety Provisions Rules 1975 Rule 120 require that safety drills should be carried out every month the States of Jersey Administration has implemented these Rules The fact that no lifejacket lights were activated indicates that safety drills might not have been sufficiently comprehensive The owner should ensure that comprehensive safety drills are carried out in future The skipper would have had ready access to a lifejacket if some had been stowed in the wheelhouse in addition to the cabin 19 SECTION 3 CONCLUSIONS 3 1 1 10 11 12 14 16
18. e Evacuation SECTION 3 CONCLUSIONS 3 1 3 2 Findings Causes SECTION 4 RECOMMENDATIONS Glossary of Terms Used Page 20 20 21 23 25 GLOSSARY ACRONYMS AND ABBREVIATIONS DSC EPIRB GMDSS GPS HRU kg kW LRC SFIA SSB Digital Selective Calling Electronic Position Indicating Radio Beacon Global Maritime Distress and Safety System Global Positioning System Hydrostatic Release Unit kilogram kilowatt unit of power Long Range Certificate metre Marine Accident Investigation Branch Maritime and Coastguard Agency Megahertz Sea Fish Industry Authority Single Side Band radio United Kingdom Universal Co ordinated Time Youth Training Scheme f MAD yy Anton mmu E UL n Pi E aw I Taser a gg Shrey 9 ISLANDS z 24 Lr ho Eyri tens AND cas s up Nani NORTH SEA u p Nay ELI aa QU c noo firey Canna EL XT feres gt i L Hoc a aN NE L gt ur fioe rr Location de fe p me M of accident A ALI ET 7 SYNOPSIS all times are UTC On 1 October 1999 an accident occurred off the Isles of Scilly involving the grounding and subs
19. equent loss of a fishing vessel resulting in one fatality The next day HM coastguard notified the Marine Accident Investigation Branch MAIB After gaining further information MAIB inspectors Captain Nick Beer and Mr Richard Barwick began an investigation The fishing vessel Rachel Harvey had been heading for St Mary s Isles of Scilly in poor weather and was approaching the eastern end of St Mary s Sound with six people on board The sole watchkeeper was navigating using a track control system that had been fitted in December 1998 and had been used extensively since The system interfaced a Global Positioning System GPS navigator with the autopilot and enabled the autopilot to steer so as to maintain the vessel on a selected track The video plotter was not being used for navigation and neither the intended track nor the vessel s position was plotted on the chart The watchkeeper did not understand how the interface functioned and tried to alter course using the autopilot s course setting knob while the interface was connected The system did not allow it The vessel grounded on Peninnis Head and foundered within two or three minutes One of the crew lost his life Due to a lack of substantive evidence it is impossible to come to a firm conclusion on the reasons why use of the track control system failed to ensure the vessel remained in safe water However irrespective of the reason why she did not track as planned the fact that the posi
20. experience he knew that the course would take the vessel close to Peninnis Head and he had suspected he would have to alter course to port to compensate for a northerly drift Until immediately before the grounding he probably remained confident that the course was a safe one because when he could see it Peninnis Head light appeared on the starboard bow However the light itself is sited about 200m inland from the end of the headland where the vessel eventually grounded 2 6 Fatigue Although the evidence suggests that fatigue was not a factor in the accident the possibility that F2 s performance was affected by drowsiness cannot be ignored Whenever a single watchkeeper is permitted to keep a watch at night sitting in a comfortable chair there is a risk that he will either fall asleep or become drowsy A watch alarm will not ensure that the watchkeeper is alert Under these circumstances it is possible that wind and tide combined to reduce Rachel Harvey s ability to 17 maintain the track with the rudder setting 1 and she drifted off to the north unbeknown to the watchkeeper 2 7 The Evacuation 27 1 Structure and equipment impeding escape 2 12 2 7 3 The canvas awning and tubular steel framework around the main deck photograph 2 particularly around the after deck might have impeded Andrew Dyson s escape The fact that his body floated to the surface indicates he was close to successfully getting clear of the vesse
21. facing forward within reach of the main instrumentation and controls The vessel s magnetic compass had been corrected about one month before the voyage in question No significant deviation had been detected The main working deck was in front of the wheelhouse A canvas shelter attached to a tubular steel framework protected the working deck The view from the wheelhouse over the shelter was restricted but adequate for safe navigation The fish hold and Vivier tank were sited below the main working deck 1 7 Safety Equipment Rachel Harvey was fitted with the safety equipment required by UK fishing vessel regulations which are largely reflected in those of the States of Jersey 8 Photograph 2 Door from galley to wheelhouse The liferaft was stowed the port side of the podium The main engine exhaust was forward on the wheelhouse top it discharged aft towards the liferaft The lifejackets were all stowed in the crew cabin Figure 2 general arrangement The lifejackets were fitted with lights that could be activated by pulling a toggle Cosalt in Newlyn had carried out a liferaft inspection on 28 May 1999 It had reinstalled the liferaft on Rachel Harvey and rigged the HRU The internal light in the liferaft was activated by withdrawing a pin which was attached to a lanyard The inflation of the liferaft put tension into the lanyard that in turn pulled the pin out activating the light automatically To conserve the battery
22. gill netting boats He had left the sea for one and a half years before returning to the industry to work on Rachel Harvey six months before the accident He was the watchkeeper at the time of the grounding Fisherman 3 F3 aged 26 had been a fisherman for five years His first three years experience had been gained on day fishing boats He had been working on larger boats like Rachel Harvey for the past two years He had undergone the statutory training in first aid survival and fire fighting He joined Rachel Harvey about three weeks before the accident Fisherman 4 F4 aged 34 had been a fisherman for 20 years He had undergone training in basic sea survival but not fire fighting or first aid He has no fishing qualifications He had once previously served on Rachel Harvey for three days earlier in the year while his regular vessel was undergoing repairs On this occasion he had joined the day before she sailed and had not kept a navigational watch on the outward bound passage Mr Andrew Dyson aged 35 deceased had relocated with his partner from London to Comwall earlier in the year and had first gone to sea as a fisherman on Rachel Harvey about two and a half months before to the accident After one voyage he left and worked on another Newlyn based fishing vessel until rejoining Rachel Harvey for the voyage in question He had not undertaken the statutory training in first aid fire fighting or survival His previous employment had bee
23. int 1 3 The Crew The 31 year old skipper had been a fisherman for 18 years He had gained nearly all his experience on potters working out of Grimsby and Scottish ports as well as from Dartmouth and Newlyn He had worked for W Harvey and Sons Ltd for between four and five years and had been skipper on Rachel Harvey for the past 18 months He underwent a youth training scheme YTS course when he first came to sea during which time he received the statutory training in first aid survival and fire fighting as well as introductory training in fishing and basic watchkeeping In addition he had obtained a Long Range Radio Certificate LRC He did not have a certificate of competency and was not required to hold for service on Rachel Harvey Fisherman 1 F1 aged 27 held a boatmaster s licence grade 2 He had worked on a salmon farm until 1995 and then on ships servicing North Sea oil rigs He had moved to the West Country at the beginning of 1998 and had worked on a 26m fishing boat for 13 months before joining Rachel Harvey in July 1999 He had been relieved as navigational watchkeeper by F2 about 35 minutes before the grounding Fisherman 2 F2 aged 25 had worked mainly as fisherman since leaving school He underwent a YTS course during which he received the statutory training in first aid survival and fire fighting as well as introductory training in fishing and watchkeeping His initial six years experience was gained on
24. l The escape route from the cabin was made much more complicated because the after deck was effectively caged in Distress messages Distress messages were transmitted in three ways by DSC on the SSB radio by VHF radio on channel 16 and by EPIRB The coastguard received all these transmissions The skipper is commended for activating the DSC distress signal and transmitting the VHF distress message he did this rather than use the little time available to retrieve his lifejacket Liferaft When the liferaft came to the surface it remained attached to the vessel by the painter The depth of water at the position of the sinking was 24m The liferaft must have been inflated by tension on the painter There is a weak link which is strong enough to inflate the liferaft but will break after the liferaft has inflated if the wreck sinks to a sufficient depth On Rachel Harvey it is apparent that the painter was long enough in relation to the depth of water to prevent the weak link parting during the initial stages During the rescue the liferaft remained attached to the vessel and therefore stationary The crew were all carried away by the tide except F4 who managed to pull himself back to the liferaft using the sea anchor rope When F4 tried to paddle the liferaft he did not realise that it was still attached to the vessel he believed the liferaft was being swept away from the people in the water One crewman tried to swim to the liferaft
25. l had a tendency to steer to starboard After thorough investigation this fault was traced to corroded solenoids which were replaced In the nine months of operation since that time the problem had not re occurred and therefore the MAIB does not consider this past problem to have been a factor in this accident Instrumentation fault It is possible that a fault with either the GPS or the autopilot unit allowed the vessel to track to the north undetected In this respect it should be noted that immediately before her departure from Newlyn Rachel Harvey had been fitted with a new rudder angle indicator which was sited on top of the autopilot unit The rudder angle indicator unit had been supplied by Navitron to be compatible with the autopilot unit It was designed to take its information from the rudder angle display incorporated into the autopilot unit itself The unit had been installed by Marconi Marine and tested prior to the vessel s departure She had steered perfectly normally on the passage to the fishing grounds and while fishing For this reason the MAIB believes that the fitting of this unit was not a factor in this accident Instrument setting fault The Navitron autopilot had been supplied for fitting to Rachel Harvey with its various functions pre set on standard factory settings As is normal on installation and during sea trials the settings would have been altered as necessary and to suit the requirements of the customer in
26. llision avoidance could have been made by this latter method The first time he had made the passage inwards to St Mary s at night and in poor weather was on 1 October On previous occasions he had been able to judge the success of any course alteration visually by reference to the land or another ship In the poor visibility and darkness of 1 October he needed to use the wheelhouse instruments In the MAIB s opinion F2 had neither enough fundamental knowledge nor sufficient training on the specific instrumentation to safely keep a navigational watch on Rachel Harvey on the night of 1 October 14 24 Hypotheses on the track control system s apparent failure to maintain the required track Despite the known shortfalls in the operation of the vessel on the night of 1 October nothing so far stated fully explains how the vessel came to ground If the waypoint was where it is said to have been and the GPS autopilot interface was correctly set up and if F2 had turned the course setter knob to alter course to port as he believes he did Rachel Harvey should not have grounded After the event the MAIB attempted to retrieve vital information from the GPS and plotter which would have substantiated or otherwise the other evidence collected However these attempts were unsuccessful and many of the fundamental factors that led to this grounding will remain unknown In the absence of firm evidence consideration bas been given to scenarios that c
27. llowing safety recommendations arising from this accident l Owners and skippers are reminded that a track control system unlike a video plotter or positions plotted on a chart does not give a continuous visual indication of the vessel s position relative to the required track It is essential to establish that clear water exists between the vessel s start position and the waypoint to which it is heading While on passage and being steered automatically the vessel s actual position must be checked by some reliable alternative means to ensure the projected track is safe Such checks will alert the watchkeeper if he is standing into danger 2 Modern technology has an important part to play in the safe navigation of vessels but in untrained hands it can lead to disaster System handbooks are often difficult to understand Hands on training is most strongly recommended for watchkeepers to ensure they can use the equipment correctly know its limitations and above all be familiar with the procedure to be used to override it to alter course 3 Track control systems should never be used in confined waters or when operating in close company of other vessels 4 A track control system will relieve the watchkeeper of certain routine tasks but NEVER his primary responsibility of maintaining a proper lookout 5 The Maritime and Coastguard Agency has issued a useful Guidance Note MGN 84 F on navigational safety Watchkeeping fishermen who may no
28. moderate to rough conditions and visibility was very poor on occasions due to rain and spray The wind was on his port bow and he suspected that the vessel would be drifting off track to the north He was also aware that on previous passages he had needed to alter course further to the south to clear the land He was aware that the land appeared right ahead on the radar which was aligned ship s head up but because of past experience he was not surprised He attempted to use the course selector knob to alter course to port to clear the land When this 11 Photograph 4 uber Head Rock off Chser Head Peninnis Lighthouse Carrickstanne Wreckage from Roche Harvey did not appear to work he tried to alter further to port but each time the vessel appeared to come back to starboard F2 put this down to the effect of the wind and tide and continued to try to alter course to port He became aware that the land was very close after he altered the range of one of the radars to 1 5 miles He did not know where the vessel was at this time but he could see Peninnis Head light just on his starboard bow The vessel was only a quarter of a mile from the coast He then saw seas breaking on rocks to starboard He shouted for the skipper to be called and the vessel grounded soon afterwards photograph 4 111 Fatigue Drugs and Alcohol There is no evidence to suggest that drugs or alcohol were factors in the accident The watchkeeper F2 had
29. n as a lifeguard and swimming instructor He was described as physically fit and a strong swimmer 14 Safety Training The UK requirement for basic safety training is specified in The Fishing Vessels Safety Training Regulations 1989 The Jersey administration does not have an equivalent requirement A number of the crew members including Mr Dyson had not undergone the minimum safety training which is required of all those who sail on UK registered fishing vessels 15 The Owner Risk Assessment W Harvey and Sons Ltd has operated fishing vessels out of Newlyn for over 40 years The company owns several vessels similar to Rachel Harvey which specialise in live lobsters crabs and crawfish At the time of the accident in compliance with The Merchant Shipping and Fishing Vessels Health and Safety at Work Regulations 1997 the company had begun to consider risk assessments covering all the normal operations of its vessels A trial risk assessment based on a Standard Risk Assessment Form supplied by the Sea Fish Industry Authority SFIA had been compiled for one of its vessels and the completed form had been submitted to the SFIA for comments W Harvey and Sons Ltd had been one of the first fishing vessel owners in the country 7 to tackle this problem It had been intended to use the first risk assessment as model for those of other vessels in the fleet including Rachel Harvey Although the comments of the SFLA had been received no
30. nor the skipper kept accurate records and in the opinion of the MAIB they failed to ensure that all new crew were adequately trained If Andrew Dyson had attended a Basic Sea Survival Course his life might have been saved 23 Watchkeeper Competence Of the five crew aboard Rachel Harvey the skipper considered four F1 F2 F3 and F4 to have been competent to keep a navigational watch The fifth Andrew Dyson had joined the vessel on its last voyage and had only joined the industry about ten weeks before the accident F2 the 13 Activity or Possible Possible hazards FIP xS Control measures necessary with respect to your vessel Wheelhouse Falling asleep on watch Vessel loss deaths boAT ATH N ST ATH ALAR Operations 1 as by Inexperience Vessel loss deaths 25 p T co DUE ERLEND Bad posture when Back injuries leg AERA Ts ww 0 ace IN EET sitting and standing problems inexperienced persons ume scolds cuts ETE ico eit GUEN IN Howse THAN 5 Cluttered working area Trips and falls excu wq ARGS FROM CLUTTER NITHIN PRACTICAL Sippey por MATS SUPLICO As Pears ec occ y Lack of hygiene Food poisoning disease 5 UESN The condition and use Explosion fire LOTE CHANGED Renu ALLY e Ce ox of vita Calor Gas vessel loss deaths foum 2 Herts co
31. nto the GPS This can be achieved by entering the latitude and longitude of the start and finish waypoints or by selecting a stored finish waypoint and selecting go to from the vessel s present position On 1 October the skipper selected the stored waypoint WP1 which he had used on numerous previous occasions He defined the track by selecting to go to that waypoint from the vessel s position at that time at the western end of his fishing grounds He then noted the required course 240 settled the vessel steering that course selected autopilot on mode and tumed the Radionav Interface switch to lo He checked that the vessel appeared to be steering correctly before handing the watch to F1 with the instruction that he required to be called ten minutes before reaching the waypoint Cross track error heading and distance and time to go information was available on the GPS display and on the radar display Additionally an indication of cross track error could be seen on the autopilot instrument panel Divers recovered the autopilot GPS and some plotter discs after the accident Despite the MAIB s attempts to retrieve data from these instruments none could be recovered Examination of the autopilot indicated the following settings at the time the vessel grounded photograph 1 e The course setter display was found to be reading about 285 e The autopilot was switched on The radionav interface switch was
32. ory and noted the course required He then steadied the vessel on the course and engaged the 3 2 SUR CHTice autopilot Next switched on the track control system by selecting Lo using the interface control switch see photograph 1 With the track control system operating he handed the watch to F1 instructing that he should be called ten minutes before arrival at the waypoint It was also F1 s duty to cook the evening meal which generally coincided with arrival in harbour To enable him to prepare the meal F1 arranged to call another fisherman F2 before arrival F2 was called at about 2010 when the vessel was still 35 minutes from the waypoint He went directly to the wheelhouse and F1 started work in the galley situated directly behind the wheelhouse There was no handover between the two watchkeepers F2 had navigated the vessel into St Mary s Sound on several occasions during his six months service on Rachel Harvey However previously it had been daylight with reasonably calm conditions The skipper always used the same waypoint which was permanently stored in the GPS s memory When F2 came on watch he noted a cross on the video plotter indicating Peninnis Head he thought this was the waypoint towards which they were heading He knew from his experience of previous passages that the waypoint appeared to be close to land He considered that he needed to alter course slightly to port to clear the land He tu
33. ough in exceptional circumstances Crow Sound was used After fishing for four or five days depending on the catch Rachel Harvey made passage for a French port where the catch was landed The voyage was completed with a return passage to Newlyn When the accident occurred the normal voyage cycle had been interrupted Rachel Harvey had been forced to lay up in Newlyn for five days One of the crew members had injured his back on the previous voyage and a replacement crew member had not been immediately available The period of inactivity ended when after five days rest the crew member s back had improved sufficiently to enable him to sail 1 2 Narrative of Events Times are UTC Rachel Harvey departed Newlyn between 1100 and 1130 on 1 October with six people on board She arrived at the fishing grounds at about 1400 and began hauling immediately The wind was south westerly force 7 and the sea was rough but this was within her working limits At 1900 after having hauled and shot about 600 pots the skipper decided to halt the fishing and make passage to St Mary s He asked the crew to let him know who was to take the first watch one fisherman F1 volunteered The skipper generally left it to the crew to establish their own watchkeeping roster He considered all but one of the five crew members to be competent to keep a navigational watch Using the GPS the skipper selected the appropriate destination waypoint from the instrument s mem
34. ould have led to the grounding These are as follows 241 F2 inadvertently altered course the wrong way When the autopilot was recovered after the accident the course setter display was found to be reading about 2859 the autopilot was switched and the radionav interface switch was on photograph 1 The divers who recovered the instrument may have inadvertently altered the setting However assuming that this was not the case the course setter reading of 285 indicates that F2 inadvertently turned the knob clockwise from the original course of about 240 By doing so in small increments he caused the vessel to track to the north ofthe planned route Although the autopilot radionav interface would have in time detected the induced cross track error and applied appropriate corrections the end result would have meant a curving track to the north of the required one During interviews after the accident F2 gave every impression that he knew the correct way to turn the course setter knob to achieve an alteration of course to port However on the night of 1 October in darkness and poor visibility he had to rely solely on the instruments to tell him his actions were correct or otherwise The MAIB believes that in these circumstances it is possible that turned the knob the wrong way 2 4 2 F2 having nearly reached the waypoint altered course to 285 towards St Mary s Sound F2 had navigated the vessel into St Mary
35. r the full autopilot control to be engaged In this mode the central dial remains fixed on a heading initially the last heading recorded when the switch was moved to on and the autopilot then applies helm to best maintain that heading Movement of the dial and therefore the selected heading can then be achieved by turning the central knob course selector knob When Autopilot Mode is rudder and yaw controls are activated The rudder control sets a limit on the maximum amount of rudder movement that can be used relative to the amount the vessel is off course This is to stop excessive amounts of rudder being applied which might cause over steering yaw control dampens the response of the system in order to protect the steering machinery from unnecessary frequent movements when the vessel is yawing in a seaway 9 pon sea 1o3 9us seAueo eJouor z When the autopilot is small changes of heading be achieved turning the course selector knob but for larger alterations of course it is recommended that the autopilot is switched to stand by or off in which modes hand steering by wheel or tiller is available e Ifthe Radionav Interface switch is turned to either lo or hi settings while the autopilot is cross track error information can be obtained from the GPS navigator The lo and
36. returned to the vessel from a five day leave period on the morning of the accident The working day had been shorter than normal and F2 had slept before coming to the wheelhouse to begin his watch 35 minutes before the grounding The evidence suggests that the watch alarm which is interfaced with the autopilot was operational and there is no evidence that it was activated on the night of the accident 12 SECTION 2 ANALYSIS 2 1 Risk Assessment The vessel s owners were in the process of forming risk assessments for all the vessels in their fleet at the time of the accident A draft risk assessment had been completed for one of their vessels which was intended to be used as a basis for the risk assessments of the others Consideration has been given to how that risk assessment identified the risks relevant to this accident and what controls were suggested to avoid them The relevant section on the form is Wheelhouse Operations where Inexperience is identified under the heading Possible Hazards with Vessel Loss and Deaths identified under Possible Consequences The necessary control measures for this risk are stated to have been training and sea survival courses and only experienced competent persons take a watch Figure extract from risk assessment These two control measures are considered below in relation to the operation of Rachel Harvey 2 Crew Training Of the six persons on board Rachel Harvey on her l
37. rned the course selector knob and selected a new course which he believed to be 10 further to port F2 monitored the navigation using one of the two radar displays both of which were aligned with the ship s head up One radar was set on the six mile range scale and the other was set on three The force 7 wind was on the port bow and visibility was reduced in occasional rain and spray F2 was concerned that the wind would be pushing the vessel to the north It was yawing in the rough conditions F2 concluded that his alteration of course to port had been insufficient and that the vessel was still heading and being forced too close to the land The land appeared on or close to the heading marker on the radar Accordingly he adjusted the course setter control further to port F2 continued to monitor the navigation He noted that the land appeared at close range on the radars and he altered the range scale of one set from 6 miles to 1 miles He saw that the closest land was about a quarter of a mile away F2 could see Peninnis Head light on the starboard bow but he was still concerned so he adjusted the course setter control further to port He did not want to disturb either F1 or the skipper unnecessarily He had always intended to call the skipper when the vessel was off Peninnis Head and she was nearing that point Soon afterwards something caused him to become very concerned and he shouted to F1 to get the skipper He looked out to star
38. s Sound on previous occasions in daylight and good weather He had remarkably achieved this by using the course setter knob to alter the vessel s heading despite the interface being turned on It is therefore conceivable that he tried to do the same thing on 1 October but misjudged the navigation and the effect of the wind and tide If he had altered the course to 285 in this way a few minutes before the grounding this would explain the setting found on the unit when it was recovered 243 was not 1 mile to the east south east of Peninnis Head The method of establishing WP1 was flawed because its precise location was never plotted on the chart The skipper believes that it was about 1 mile east south east of Peninnis Head the majority of the crew from their experience believes that it was closer to the land Because the precise start and finish positions of the planned track were unknown and 15 2 4 4 2 4 5 2 4 6 not plotted chart it must remain possibility that one or both of them were not where they were thought to be and this caused the vessel to ground Steering Fault It is possible that a fault in the vessel s steering system caused her to steer to starboard of the planned track undetected In this respect it should be noted that the vessel had a history of steering problems before the change of instrumentation that took place in December 1998 In particular a problem had occurred which meant the vesse
39. t 1 mile east south east of Peninnis Head The exact position of this waypoint is unknown as the memory could not be retrieved from the instrument after the accident and no other record of it existed It had been entered when the skipper considered the vessel to be physically in the appropriate position He had judged this by eye using his experience and then read off the position from the GPS entered it in the memory and called it WP1 The position had never been plotted on a chart The waypoint had been used on nearly every passage from the fishing grounds to St Mary s since that time The watchkeepers from their experience considered the point to be closer to the headland than the skipper had judged F2 was under the impression that it actually marked the headland itself At the start of the passage to St Mary s on 1 October the skipper handed over to F1 who was subsequently relieved by F2 The only indication of the vessel s performance in track keeping was the digital and pictorial displays of cross track information which could be viewed on the autopilot panel the GPS and the radar No positions or courses were marked on the chart and neither the waypoint nor the track were displayed on the video plotter 110 The Grounding On 1 October F2 was aware that strong tidal currents are sometimes present in the area to the east of St Mary s but he was unaware of which direction they should be setting The vessel was yawing considerably in the
40. t be familiar with this document and its advice for keeping a safe navigational watch should read it carefully It addresses over reliance on the use of electronic navigation systems The following are additional recommendations The States of Jersey Administration is recommended to 2 Implement basic safety training regulations for fishing vessel crews as soon as possible Navitron Systems Ltd is recommended to 2 Consider redesigning its operations manual for the NT 921 autopilot 23 The Owner W Harvey and Sons Ltd is recommended to 3 Ensure comprehensive safety drills are carried out at monthly intervals on board its vessels 24 Glossary of Terms Used Autopilot an instrument that steers a vessel on a set compass heading Cross track error deviation from the intended track international distress message transmitted by voice Painter a line attaching the liferaft to the vessel via a weak link Podium the platform at the aft end above the main deck used mainly as a store for pots dan buoys etc Senhouse slip a device used for securing the liferaft canister releasing the slip allows manual deployment of the liferaft Track Control System a system that automatically maintains a vessel on a predetermined track Vivter tank a tank designed for storing live shellfish 25
41. the rudder restriction in applying corrective action In the course of the investigation the MAIB was told that the operations manual for the autopilot was difficult to understand A copy of the Navitron NT921 Installation and Operations Manual was studied and considered to be poorly laid out and difficult to follow It is possible that these factors combined to allow the vessel to track to the north of the planned route where she grounded despite F2 s attempts to alter the heading to port 25 Cause of the Grounding Due to lack of substantive evidence it is impossible to come to a firm conclusion on the reasons why use of the track control system failed to ensure the vessel remained in safe water Any one or any combination of the above hypotheses may have caused the vessel to be to the north of the required track by a sufficient amount to cause her to ground However irrespective of the reason why she did not track as planned the fact that the position of the vessel was not closely monitored by plotting on the chart or by use of the video plotter during the passage meant that the fault went undiscovered The MAIB believes therefore that this fundamental shortfall in the vessel s navigational management was the principal causal factor in the grounding Without confirmation of the vessel s position and her track made good F2 did not become sufficiently concerned to call F1 or the skipper until grounding was imminent From previous
42. tion of the vessel was not closely monitored by plotting on the chart or by use of the video plotter meant that the failure went undiscovered This fundamental shortfall in the vessel s navigational management was the principal causal factor in the grounding Recommendations are directed at improving safety and navigational training on board fishing vessels VESSEL AND ACCIDENT INFORMATION Vessel Name Type Registry Fishing Number Length Overall Length Registered Gross Tonnage Built Hull Material Propulsion Propulsive Power Owner Crew Accident Type of Accident Date of Accident Time of Accident Place Weather Tide Sea Conditions Injuries Damage Pollution Rachel Harvey formerly Le Cap 3 98 Fishing vessel potter Jersey J91 17 62m 16 25m 55 47gt 1959 Wood Diesel engine Moteurs Baudouin 6P 15 2 S 246kW W Harvey and Sons Ltd Newlyn Cornwall TR18 5 6 Grounding followed by foundering 1 October 1999 2046 UTC Peninnis Head Isles of Scilly Wind SW force 7 rain showers mainly good visibility but poor in showers North easterly 1 knot Moderate in lee of land One fatality Extensive hull damage fishing vessel foundered Limited up to about 4500 litres of diesel fuel SECTION 1 FACTUAL INFORMATION 11 Background to the Accident The Jersey registered fishing vessel Le Cap was bought by the Newlyn based company W Harvey and Sons Ltd in September 1996 The new owners
43. to lo e was selected on the rudder control e was selected on the yaw control 10 1 9 Bridge Watchkeeping and Navigation In general while the vessel was actively fishing the skipper manned the wheelhouse and had control of the navigation When on passage those crew members whom the skipper considered to be competent to keep a watch shared the bridge watchkeeping duty There was no strict rotation it was left up to the crew to decide who would take the watch on each occasion Generally the length of each watch was about one and a half hours or 10 miles passage distance Except for the passage to and from France to land the catch passage times were short normally less than three hours The video plotter was not usually used for navigation on passage although it was used during fishing operations to record the positions of the pots A chart of the area was available on the chart table but not often referred to The track control system was used extensively by the skipper sometimes during fishing operations and always on passage During the nine months in which the system had been in operation on board the skipper had found it a useful and reliable instrument On the first voyage after it was fitted the skipper entered strategic waypoints into the memory of the GPS One such waypoint intended as the principal landfall for visits to St Mary s and numbered in the memory as WP1 was judged to have been abou
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