2011X71 Man Overboard - Leeuwin

Man Overboard - Leeuwin
- Australia

- Report No. 7040OR

The Nautical Institute has taken a leading role in"Square Rig" training and Sail Training Vessels are becoming increasinglypopular. Safety standards are given a high priority on these vessels and,fortunately, accidents are rare. However, a timely warning has come as aresult of a tragic accident which happened to a volunteer crew member lastyear. The full report can be obtained from: Inspector of Marine Accidents,Marine Incident Investigation Unit, Department of Transport and RegionalDevelopment, PO BOX 594, CANBERRA ACT 2601. Tel 06 247 7324, Fax 06 2476699. Email [email protected] Internet address http://www.dot.gov.au/programs/miiu/miiuhome.htm
Narrative

Leeuwin is a steel hulled barquentine, having three masts, square riggedon the foremast and fore/aft rigged on the main and mizzen masts. She hasan overall length of 55m, a beam of 9m and under full sail carries 810m2of sail. The vessel is normally manned by a small nucleus of permanent crew Master, Mate, 2nd Mate/Bosun, Engineer and Cook supported bya volunteer crew of Watch Officer, four Watch Leaders, Purser, Bosun's Mateand Cook's Mate who are drawn from the Sail Training Association of WesternAustralia. Watch Leaders are chosen carefully for their leadership qualitiesand abilities with young people; many of them first sailed as trainees onboard and then acted as volunteer crew members on one day sailings and occasionallyon longer voyages as Cook's Mate before being selected and trained as WatchLeader. The main program for the vessel is "geared towards a personaldevelopment exercise that makes trainees more aware of their capabilitiesrather than an instruction in sailing", the purpose being "tohelp young people to mature and develop in areas of self esteem, discipline,team work, leadership and good citizenship".

When trainees first join Leeuwin, they are mustered for a welcome andan introductory talk by the Master and the Mate, which includes generalsafety issues. Safety belts are issued to everyone with the instructionsthat they are to be worn at all times when on deck, even if on deck forrelaxation purposes. The Mate demonstrates their correct fastening, stressingthe need for the end to be doubled back through the buckle, to prevent itfrom coming undone and explaining the possible consequences of failure todo this. The Trainees are divided into four watches and introduced to theirWatch Leaders, who take them individually through safety belt fastening.The four watches then rotate through various instructional sessions includinggoing aloft with the Watch Leader. The trainees are instructed that whenmoving aloft they should always have three points in contact with the rigging,2 feet and 1 hand or 2 hands and 1 foot, also that when working aloft, onthe bowsprit, or outboard, they should always clip on their safety line.Trainees do not have to go aloft and this activity is purely voluntary.Normally for their first venture aloft they are taken up the foremast, firstto the lower yard, then to the foretop or platform which requires the traineesto negotiate the futtock shrouds. Negotiating the futtock shrouds is perhapsthe most difficult and potentially dangerous aspect of climbing aloft. Toavoid a person having to unclip and reattach their safety line while negotiatingthe futtock shrouds, a special safety rail has been fitted.

The Incident

Various training sessions took place during the first two days of thevoyage, during these, 3 trainees out of the 8 in Red Watch decided not togo aloft. At 0800 on the third morning, Red Watch was given the task ofsetting the main sail gaff. The Watch Leader was a young woman sailing forthe first time in this role. She mustered the Watch by the port (windward)side mainmast shrouds and explained what had to be done. Three traineeswere needed to climb to the main top to release the sail.

The watch Leader invited one of the men and one of the women to undertakethe job and then another woman, one in her late twenties who had not venturedaloft as far as the tops before, volunteered to make up the trio. As thiswas the Watch's first time aloft on the mainmast, the Watch Leader's dutywas to go first to lead the way. As it was the 2nd woman's very first climb,the first, younger woman was appointed to be her "buddy" and tohelp her as necessary. The Watch Leader climbed first, followed by the man.Initially the two women climbed side by side, the elder of the two usingand repositioning her safety line as she went. As the shrouds narrowed,making side by side ascent impossible, the younger woman stopped and allowedthe other to go ahead.

When the man had negotiated the futtock shrouds and was safely on themaintop, the Watch Leader instructed him to help the woman and then movedover to the sail to locate the gasket knots. The man knelt down so as tobe in a better position to provide help and advice to the woman below him.The Watch Leader, having quickly located the gasket knots then moved tostand behind the kneeling man and observed the woman's progress. The womanarrived at the bottom of the futtock shrouds and clipped her safety lineonto the safety rail, placing her left arm onto the shrouds for securityas she did so. Looking down, she became frightened and wanted to climb downand, instead of climbing up the futtock shrouds, she tried to climb behindthem, first from for'd then from aft. Encouraged and guided by the others,she was eventually in the correct position for climbing them, but then tooka short rest, hooking both her arms over one of the ratlines.

Apparently determined to go on, the woman resumed the climb and reachedthe position where she had both hands on the bottom ratline of the maintopmast shrouds. She then became very frightened, stopped and called tothe others that she was frightened. The Watch Leader told her to hang onand that she was on her way down to help her but before she could move thewoman let go with both hands and then screamed as she fell. The Watch Leaderexpected the woman's safety line to arrest the fall but, after being arrestedvery briefly the woman continued her fall, striking the other woman on theshrouds beneath her as she fell. Initially she fell down the outside ofthe shrouds but then fell clear a few metres from the deck, falling slightlyhead first. Instinctively, she grabbed for, and her left arm caught over,the nock sail sheet, belayed on the pin bar immediately inboard of the shrouds.This partially arrested her fall and caused her to pivot so that she landedlegs first on the main staysail sheet which was coiled on the deck justforward of the shrouds. The woman's safety line was still fastened to thefuttock shroud safety rail, the safety belt which was unfastened was suspendedfrom it.

Although when tested and fastened correctly the belt held a test dummyconforming to AS2227, it is considered that it would be appropriate forthe Leeuwin Foundation to reassess the safety belt used aboard LEEUWIN againstthe harnesses used by other sail training establishments

Conclusions

The trainee had not fastened her safety belt properly so that it came undone instead of preventing her from falling further.
The absence of a safety check system, which meant that the trainee was able to climb aloft with an improperly fastened safety belt.
The onboard philosophy and procedures that removed the safety barrier of safety belt checks before trainees ventured aloft.
The onboard procedures which allowed trainees to climb aloft for the first time on the mainmast.
The absence of an onboard philosophy or procedure whereby a trainee with a slow learning capability is afforded supplementary attention.
It is also considered that the shiny surface of the well-worn, fine-weavewebbing created difficulty in the tight fastening of the safety belt, whichmay have contributed to the trainee not fastening the belt correctly. Itis further considered that the trainee's death was averted only by her leftarm hooking over the nock sail sheet.