Report from CYC on lost crew in Mac race.

[Davidasailor26]

The crew were calling out to him .. why didn't he call back when it appeared that he was calm and relatively at ease in the water?

Pure speculation, but I'll try at an answer - Either he did call out and wasn't heard over the flogging sails, or he figured that they saw him and he didn't need to call back.

Why didn't he attempt the manual inflation? Could it be that he misjudged the situation himself?

That's my guess. He may have figured he was better off with the flexibility to swim than needing the other flotation. Either that or he was in some amount of shock and not thinking clearly about the fact that he had the option. One other thing I was thinking though is that maybe he did try to pull the manual inflation handle and it also failed. The report seemed focused on the witnesses saying they never saw him reach for it, but really would people hundreds of yards away on a bouncing boat in 6' seas and flogging sails be able to tell if he had tried to reach for a 3" piece of plastic under the water?

 

[Scott T-Bird]

Coincidentally, I've been taking an OSHA 30 Hr course on-line. I'm sure nobody would ever want to get OSHA involved in sailing competition, but this report almost bears the mark of an "Incident Report". I'm reminded that there is a hierarchy of controls in the workplace when dealing with safety hazards. It is as follows:
1. Discontinue or modify the activity to avoid the hazard.
2. Utilize Engineering Controls to reduce the hazard.
3. Utilize Administrative Controls to reduce the hazard.
4. Utilize Personal Protection Equipment (PPE).

Well, just as there are jobs that are hazardous, but they have to be done, we know that there is an over-powering element of human nature that craves competition, especially competition that involves risk and reward. So, avoiding the activity of sailing competition is out of the question.

Engineering Controls involve the sailboat design. These are the highest in the hierarchy of controls to mitigate risk when the activity cannot or will not avoid the hazard. Engineering controls are considered to be the most important element of safety. The boats must be designed and constructed for a reasonable degree of safety. The elements of boat design that take safety into account are innumerable. This could be a novel, so I'm going to come back to this only to make a point.

The Administrative Controls were laid out quite elaborately by the Committee Report. In fact, this seemed to be the primary focus of the report. They laid the report out like an Incident Report, and very adequately defended the Chicago Yacht Club Committee for their safety controls and standards and actions during the incident. I would find no fault whatsoever for their Administrative Controls and I don't find any reason to believe they were responsible for the incident, or could have prevented it with additional controls that are within their realm of responsibility.

We all seem to focus on the PPE's. Why not on a tether? Why did PFD inspections fail? Why weren't the markers deployed? Why weren't communications better? All good points and questions … completely valid. BTW, it is the employer's responsibility to provide PPE's to employees. It is important to note that PPE's are at the lowest level of the hierarchy in safety.

It appears that the boat owner actually did provide most necessary gear, but perhaps they should be more diligent about what they provide and how it is maintained. The report seems to skim through this responsibility in an effort not to be too harsh on their friends. Under the circumstance, I can understand.

The rescue effort would seem to be a separate realm from the hierarchy that I laid out. It would seem that rescue efforts are the last resort, after the hierarchy fails. There would seem to be some problems with the rescue effort (COB drills, etc - laid out in Administrative Controls) but I won't be pointing them out because I don't have a lot of confidence that I could have or would have done better.

An Engineering Control is where I think the most glaring failure would be. Why does the transom need to be so open that a full grown man could so easily roll right off the end of the boat from the cockpit? It would seem to me that an adequate barricade could have and should have been designed and constructed into the boats structure. I'm left wondering why it was not mentioned in the report and I'm baffled how boat designers have so long been avoiding how to address such an obvious fault.

 

[Davidasailor26]

Coincidentally, I've been taking an OSHA 30 Hr course on-line. I'm sure nobody would ever want to get OSHA involved in sailing competition, but this report almost bears the mark of an "Incident Report". I'm reminded that there is a hierarchy of controls in the workplace when dealing with safety hazards. It is as follows:
1. Discontinue or modify the activity to avoid the hazard.
2. Utilize Engineering Controls to reduce the hazard.
3. Utilize Administrative Controls to reduce the hazard.
4. Utilize Personal Protection Equipment (PPE).

Well, just as there are jobs that are hazardous, but they have to be done, we know that there is an over-powering element of human nature that craves competition, especially competition that involves risk and reward. So, avoiding the activity of sailing competition is out of the question.

Engineering Controls involve the sailboat design. These are the highest in the hierarchy of controls to mitigate risk when the activity cannot or will not be activated. Engineering controls are considered to be the most important element of safety. The boats must be designed and constructed for a reasonable degree of safety. The elements of boat design that take safety into account are innumerable. This could be a novel, so I'm going to come back to this only to make a point.

The Administrative Controls were laid out quite elaborately by the Committee Report. In fact, this seemed to be the primary focus of the report. They laid the report out like an Incident Report, and very adequately defended the Chicago Yacht Club Committee for their safety controls and standards and actions during the incident. I would find no fault whatsoever for their Administrative Controls and I don't find any reason to believe they were responsible for the incident, or could have prevented it with additional controls that are within their realm of responsibility.

We all seem to focus on the PPE's. Why not on a tether? Why did PFD inspections fail? Why weren't the markers deployed? Why weren't communications better? All good points and questions … completely valid. BTW, it is the employer's responsibility to provide PPE's to employees. It is important to note that PPE's are at the lowest level of the hierarchy in safety.

It appears that the boat owner actually did provide most necessary gear, but perhaps they should be more diligent about what they provide and how it is maintained. The report seems to skim through this responsibility in an effort not to be too harsh on their friends. Under the circumstance, I can understand.

The rescue effort would seem to be a separate realm from the hierarchy that I laid out. It would seem that rescue efforts are the last resort, after the hierarchy fails. There would seem to be some problems with the rescue effort (COB drills, etc - laid out in Administrative Controls) but I won't be pointing them out because I don't have a lot of confidence that I could have or would have done better.

An Engineering Control is where I think the most glaring failure would be. Why does the transom need to be so open that a full grown man could so easily roll right off the end of the boat from the cockpit? It would seem to me that an adequate barricade could have and should have been designed and constructed into the boats structure. I'm left wondering why it was not mentioned in the report and I'm baffled how boat designers have so long been avoiding how to address such an obvious fault.

I agree with all of your points. Every once in a while (maybe more on other forums than here), someone will say "boats from brand X aren't made for sailing, they're just floating condos, look at the salon - no hand holds anywhere". Now, a TP52 isn't a floating condo. Why isn't the design held to a standard for keeping people in the boat when they're standing out in such a vulnerable place? The changes don't need to significantly degrade the boat's performance, so I don't know why they aren't in place already, and aren't mentioned in the report.

 

[Parsons]

Going down @Scott T-Bird 's line of thought that perhaps we can learn something about safety from actual safety experts ... In which of the OSHA categories would you place Attitude? Without trying to criticize this particular crew, particularly Jon, I would like to discuss the machismo racing culture. I've been on amateur race boats, and heard about others, where crew did absolutely reckless things to save a few seconds in a race, or even just to show how manly they were. It does not make the boat any faster to not wear a PFD / harness to switch head sails at night, but this activity is almost common. I've never been a good enough sailor, or interested, to try for a spot on a truly competitive boat like these TP52's, but I expect that the macho attitude gets progressively greater.

BTW: If any of you are not already familiar with his work, I recommend reading the articles of Mario Vittone on Soundings: (https://www.soundingsonline.com/voices/lifelines-safety-and-rescue-at-sea) . He's the author of the "Drowning doesn't look like drowning" article that many of you are familiar with, which was quoted in this CYC paper. I refer you to his article about "Why experience doesn't matter" and "Putting crew in the water for a rescue", which we have discussed in this thread.

 

[Scott B]

Pure speculation, but I'll try at an answer - Either he did call out and wasn't heard over the flogging sails, or he figured that they saw him and he didn't need to call back.

That's my guess. He may have figured he was better off with the flexibility to swim than needing the other flotation. Either that or he was in some amount of shock and not thinking clearly about the fact that he had the option. One other thing I was thinking though is that maybe he did try to pull the manual inflation handle and it also failed. The report seemed focused on the witnesses saying they never saw him reach for it, but really would people hundreds of yards away on a bouncing boat in 6' seas and flogging sails be able to tell if he had tried to reach for a 3" piece of plastic under the water?

Either that or he was in the early stages of drowning.

 

[jssailem]

Scott. Like the analysis using your skill training to evaluate the report of events.

Not having a TP52 to rent out or play on, I am left to focus on my boat and the nature of risks that I expose myself and guest to during sailing adventures.

Your structure of

hierarchy of controls in the workplace

is a good tool for such consideration.

I wonder how you have looked at your own sailing plans and what type of alterations are suggested.

I for one will be using my Dry Suit more often. Thank you @Parsons for the "Soundings" link.

 

[Johnb]

The victim, John Santarelli was a current tri-athlete and an excellent swimmer. How many of us are in comparable physical condition...not many.

Speaking as one who has a plentiful layer of lard but is reasonably fit I can out float and in cold water than any super athlete.

You maintain your gear, you train your MOB drill, and you effectively execute a MOB.
Only one of the above three improves the reliability of the PFD.

As an aside, note that the great lakes are fresh water and for a 200 pound person that makes about 5 pounds of buoyancy difference from the ocean.

 

[MitchM]

to me, the most interesting lessons were : 1/ Imedi should have, but did not immediately broadcast a mayday / MOB. other boats in the vicinity saw them doing 720 s but did not immediately realize it was a mayday/ attempt at MOB crew recovery. 2/ Imedi did not enter the la/lo of the MOB immediately , as the ipad to do so was down below deck; 3/ the 'autoinflate' life vests for the crew were the ones which 'came with the boat' when it was purchased , and 4/ the coroner sent the victim's life preserver off to be incinerated, instead of turning it over to the USCG to be tested...

 

[Jumpstart]

Parsons you are projecting. The "macho" culture might exist in dinghys and small boats but I've never seen it in the 6 Macs I have done on a GL70. The crew tends to be quite capable and level headed. With the high loads on these boats being macho will get you killed or maimed at best. Scott T-Bird most likely had it pegged when he said that Jon seemed to be o'k then he wasn't. That mirrors what I have seen in our erstwhile MOB drill. The other thing is that it is extremely difficult to position a boat in those conditions. You slow the boat down enough to effect a rescue and the waves push you all over the place. I still can't imagine why the MOM unit wasn't deployed immediately. Pulling a pin and it self deploys. Even trailing the lifesling would give the man overboard some chance if you missed him. I'm glad I had my MOM8 recertified last year. There was a problem with the inflatable mast.

 

[Davidasailor26]

1/ Imedi should have, but did not immediately broadcast a mayday / MOB. other boats in the vicinity saw them doing 720 s but did not immediately realize it was a mayday/ attempt at MOB crew recovery. 2/ Imedi did not enter the la/lo of the MOB immediately , as the ipad to do so was down below deck;

I agree that those are lessons learned - that in general in a MOB situation those actions should be better coordinated. But I'm not sure they would have made a difference to the outcome of this specific case. Imedi never did lose sight of the MOB, and they were able to get their own boat to him as fast as anyone else would have. At least one other boat was already there too, but they couldn't get close enough to attempt a rescue as Imedi was circling in the area. More boats approaching from an earlier VHF call would have likely had the same problems, unless there was a lower freeboard or more maneuverable boat that could have been on the spot and replaced Imedi before John within those first 4-5 minutes.

 

[Mikem]

The rescue crew, in any situation, should not count on the ability of the "strong swimmer" to effect his own rescue or even be able to swim to a thrown device close aboard (but throw all devices anyway). In conditions other than benign and an uninjured person overboard it is very difficult to swim and the PFD, inflatable or otherwise, makes it almost impossible. After a forced open ocean ditching due to material failure in a Navy helicopter it was all I could do to dog paddle in full flight gear and inflated survival vest. The water was flat as a dining room table top and warm. Getting into the life raft was relatively easy as the rest of the crew hauled me in. The lesson here is practice with your boat to get as close as possible to the victim and as the victim practice inflating the vest orally. It looks like the sea state in this tragic incident worked very much against them.

 

[capta]

I do feel the pain of his friends and family, but how many years have they been running that race? Half a century or more?
I'd think by now that if someone was intent on racing in frigid water, in the weather commonly occurring on that lake, they'd know what was required to keep the crew safe.
Sorry, but no amount of discussion on this or any other forum can solve stupid!

 

[Davidasailor26]

racing in frigid water,

But the water was about 70 degrees. Not tropical, but not hypothermic in the 5 or so minutes from the time when he fell in until he went under. Even the weather wasn't really all that wild - 25 knot winds and 6-8 foot seas. I agree that the crew seemed unprepared to handle the emergency in those conditions, but how to learn from that lack of preparedness is worth discussion, not degrading.

 

[FDL S2]

Going down @Scott T-Bird 's line of thought that perhaps we can learn something about safety from actual safety experts ... In which of the OSHA categories would you place Attitude? Without trying to criticize this particular crew, particularly Jon, I would like to discuss the machismo racing culture. I've been on amateur race boats, and heard about others, where crew did absolutely reckless things to save a few seconds in a race, or even just to show how manly they were. It does not make the boat any faster to not wear a PFD / harness to switch head sails at night, but this activity is almost common. I've never been a good enough sailor, or interested, to try for a spot on a truly competitive boat like these TP52's, but I expect that the macho attitude gets progressively greater.

BTW: If any of you are not already familiar with his work, I recommend reading the articles of Mario Vittone on Soundings: (https://www.soundingsonline.com/voices/lifelines-safety-and-rescue-at-sea) . He's the author of the "Drowning doesn't look like drowning" article that many of you are familiar with, which was quoted in this CYC paper. I refer you to his article about "Why experience doesn't matter" and "Putting crew in the water for a rescue", which we have discussed in this thread.

I've spent over 20 years in manufacturing and as part of my job I've taken the class (or a very similar one) Scott is referencing. In my opinion attitude falls under Administrative controls. I say this because knowing risks can only be done by educating the workforce (or crew in this case) on potential hazards and this falls on leadership to provide and document that education. we have all employees (including office personnel) sign off on all safety training-which is cya and might not be practical for a sailing crew.

 

[Parsons]

Parsons you are projecting. The "macho" culture might exist in dinghys and small boats but I've never seen it in the 6 Macs I have done on a GL70. The crew tends to be quite capable and level headed. With the high loads on these boats being macho will get you killed or maimed at best. Scott T-Bird most likely had it pegged when he said that Jon seemed to be o'k then he wasn't. That mirrors what I have seen in our erstwhile MOB drill. The other thing is that it is extremely difficult to position a boat in those conditions. You slow the boat down enough to effect a rescue and the waves push you all over the place. I still can't imagine why the MOM unit wasn't deployed immediately. Pulling a pin and it self deploys. Even trailing the lifesling would give the man overboard some chance if you missed him. I'm glad I had my MOM8 recertified last year. There was a problem with the inflatable mast.

Based on this statement, you have much more large race boat experience than I have, so let me ask a few questions to clarify. In your experience on the GL70's, and the previous comments on this thread:

• How would your crews have dealt with a real MOB? Do you think that the results would have been the same, or would a recovery have happened?
• What is the pre-race team training like? This report described a 2-minute safety talk and pulling a hat out of a calm harbor. Does your team train for emergencies or unexpected conditions together?
• What is the compliance with personal protective equipment (PPE) really like? This report describes some, but not complete, maintenance. It also describes about 50% use of the equipment on a challenging, but not survival, daylight race. Is there 'management' expectation of 100% safety equipment use, or whatever the crew feels like?
• Is the deck layout and other equipment designed to keep people on the boat? Since it's only a class, I would think that there is some variation in the stern build, but some photo's on the interweb show the same open-stern / lifeline arrangement as described.

I agree that recovering a COB in any situation is difficult, which is why @Scott T-Bird keeps asking about safety before anyone is wet. I think that most sailors do not have an appreciation for the difference in risk in re-boarding a high-freeboard keel boat and a canoe or dingy in the lake. I'm asking about machismo because I have seen it in crews in beer-can racing, and it's difficult to dissuade and dangerous.

 

[Jumpstart]

• How would your crews have dealt with a real MOB? Do you think that the results would have been the same, or would a recovery have happened? It is hard to say. It really depends on how much the crew has sailed together
• What is the pre-race team training like? This report described a 2-minute safety talk and pulling a hat out of a calm harbor. Does your team train for emergencies or unexpected conditions together? We always did the MOB drill with a live subject on the GL70. On other boats I have done the race with they used a cushion which in my opinion was not as effective.
• What is the compliance with personal protective equipment (PPE) really like? This report describes some, but not complete, maintenance. It also describes about 50% use of the equipment on a challenging, but not survival, daylight race. Is there 'management' expectation of 100% safety equipment use, or whatever the crew feels like? We wore lifejackets on deck at all times. Even though the owners supplied PFDs everyone brought their own jackets with integral harnesses.
• Is the deck layout and other equipment designed to keep people on the boat? Since it's only a class, I would think that there is some variation in the stern build, but some photo's on the interweb show the same open-stern / lifeline arrangement as described. Some had an open stern with a sugar scoop. Our boat had a closed stern. My personal boat has an open transom with double lifelines which seems to work well.

The wave conditions when the accident happened played a big part in this. These are not 6-8 foot ocean waves. Because of proximity to shore and the breakwalls in the area the waves are steep, confused, and with occasional rogues. Even on the big boats you get bounced around pretty good. with a 14' beam you are pretty high off the water when the boat is heeled as it was in this case. A water temp of 70 degrees is warm for Lake Michigan. As you head north it becomes progressively colder. 55 degrees would be a more common temp at the north end of the lake.