There is one thing that strikes me about this tragedy that is not mentioned by anybody, and not even mentioned in the report. He slipped out the stern with hardly any restraint. The report and crew testify that he seemed to hit the stanchion pretty hard. Why is there a need for the stern to be so completely open? When I started reading this thread, I was thinking the poor guy went over the lifelines. But no, he was in the cockpit and he slid right through the open stern! Doesn't it seem odd that there is no mention that a secure cage at the stern would have prevented him from sliding in?
I'm sure that there are reasons for the open stern, but it also looks like a glaring safety weakness to me. It's just a little coincidental that I am reading this report while at the same time, I'm taking an OSHA 30 Hour course for work requirements. Barricades are the primary controls for safety, is what I'm studying.
If there were a secure barrier at the stern, this tragedy would not have happened. That seems to get lost in all of the discussion about under-utilized safety devices, inoperable inflation device, etc. There wasn't any mention about the nature of the open stern design (lacking an effective barricade) and how it contributed, actually, how it was primarily responsible, for the way the crew exited the boat. It also occurred to me that with all of their experience at sea, it does not appear that there was a single crew member whom had any real-world experience with COB - it goes to show that casually practicing the maneuver may not be effective when the circumstances are substantially more chaotic. I didn't really read deeply enough so I might have missed something in the report otherwise. It does seem that the complexity of the boat hinders the recovery, particularly with the sea-state and wind.