The MAIB has released its report and safety flyer from the investigation of the loss of the yacht Cheeki Rafiki and her crew in the Atlantic on 16 May 2014.
The Marine Accident Investigation Board (MAIB) has conducted as thorough investigation as possible into the loss of the Cheeki Rafiki in May last year. The Investigation was constrained by the lack of witnesses or material evidence, but has used all information available to surmise the likely causes and factors that led to the loss of the Cheeki Rafiki.
Cheeki Rafiki, a Beneteau First 40.7, was being sailed by four British yachtsmen, all of whom were preumed dead after the incident: skipper Andrew Bridge, Paul Goslin, Steve Warren and James Male.
We have reproduced the Synopsis, Safety Lessons and Actions Taken. The full report and safety flyer can be downloaded here:
MAIB Report Synopsis
At about 0400 on 16 May 2014 the UK registered yacht Cheeki Rafiki capsized approximately 720 miles east-south-east of Nova Scotia, Canada while on passage from Antigua to Southampton, UK. Despite an extensive search that found the upturned hull of the yacht, the four crew remain missing.
At approximately 0405 on 16 May an alert transmitted by the personal locator beacon of Cheeki Rafiki’s skipper triggered a major search for the yacht involving United States Coast Guard fixed-wing aircraft and surface vessels. At 1400 on 17 May, the upturned hull of a small boat was located; however, adverse weather conditions prevented a closer inspection and the search was terminated at 0940 on 18 May.
At 1135 on 20 May, following a formal request from the UK government, a second search
was started. At 1535 on 23 May, the upturned hull of a yacht was located and identified as being that of Cheeki Rafiki. On investigation, it was confirmed that the vessel’s liferaft was still on board in its usual stowage position. With no persons having been found, the second search was terminated at 0200 on 24 May. Cheeki Rafiki’s hull was not recovered and is assumed to have sunk.
A combined effect of previous groundings and subsequent repairs to its keel and matrix had possibly weakened the vessel’s structure where the keel was attached to the hull.
In the absence of survivors and material evidence, the causes of the accident remain a matter of some speculation. However, it is concluded that Cheeki Rafiki capsized and inverted following a detachment of its keel. In the absence of any apparent damage to the hull or rudder other than that directly associated with keel detachment, it is unlikely that the vessel had struck a submerged object. Instead, a combined effect of previous groundings and subsequent repairs to its keel and matrix had possibly weakened the vessel’s structure where the keel was attached to the hull. It is also possible that one or more keel bolts had deteriorated. A consequential loss of strength may have allowed movement of the keel, which would have been exacerbated by increased transverse loading through sailing in worsening sea conditions.
The yacht’s operator, Stormforce Coaching Ltd, has made changes to its internal policies and has taken a number of actions aimed at preventing a recurrence. The Maritime and Coastguard Agency has undertaken to work with the Royal Yachting Association to clarify the requirements for the stowage of inflatable liferafts on coded vessels, and the Royal Yachting Association has drafted enhancements to its Sea Survival Handbook relating to the possibility of a keel failure.
A recommendation has been made to the British Marine Federation to co-operate with certifying authorities, manufacturers and repairers with the aim of developing best practice industry-wide guidance on the inspection and repair of yachts where a glass reinforced plastic matrix and hull have been bonded together. A recommendation has also been made to the Maritime and Coastguard Agency to provide more explicit guidance about circumstances under which commercial certification for small vessels is required, and when it is not.
Further recommendations have been made to sport governing bodies with regard to issuing operational guidance to both the commercial and pleasure sectors of the yachting community aimed at raising awareness of the potential damage caused by any grounding, and the factors to be taken into consideration when planning ocean passages.
- Matrix detachment is possible in yachts where a GRP matrix and hull are bonded together. The probability of this occurring will increase with longer and harder yacht usage. There is therefore a need for regular structural inspection by a nominated competent person as part of a formal verifiable procedure, as well as before embarking on an ocean passage.
- Owing to the continuous nature of a matrix where solid floors are in place, particularly where the keel is attached to the hull, it may be difficult to readily identify areas where a detachment has occurred. There are differing opinions among surveyors and GRP repairers with regard to what are appropriate methods of inspection and repair, including the circumstances in which the keel should be removed. There is therefore a desire for best practice industry-wide guidance to be developed.
- Any grounding has the potential to cause significantly more damage than may be subjectively assessed or visually apparent, including matrix detachment. It is therefore important that all groundings, including those perceived to be ‘light’, result in an inspection for possible damage by a suitably competent person.
- Ocean passages require comprehensive risk assessment and contingency planning. A compromise needs to be made between planning a high latitude route, to pick up favourable winds and ensure a speedier passage, and a low latitude route, to avoid particularly adverse weather at the expense of a slower passage possibly necessitating additional port calls. Weather routing, vessel tracking and frequent communications from a shore-based support cell can significantly reduce the risks.
- Attached keels are a feature of modern yacht design. Operators and crews therefore need to be aware of the associated danger of keel detachment, and have preventive procedures in place to reduce the risk, e.g regular inspection of the keel attachment area and checking of keel bolts, and documented actions to take in the event of flooding, including reducing the load on the keel and preparing for the yacht capsizing and inverting.
- Search and Rescue mid-ocean is hampered both by the time it takes fixed-wing search aircraft to arrive and their ability to assist when on scene. Consideration therefore needs to be given to how the alarm will be raised, both by the quickest means and with an accurate position. Wearing a Personal Locator Beacon provides additional assurance that the alarm can be raised if it has not been possible to deploy the vessel’s EPIRB.
- It is likely to take many hours or even days before SAR assistance can be provided mid- ocean, during which time being able to board a liferaft will be key to survival. In small craft there will be a trade-off between positioning the liferaft so it will deploy automatically in the event of an emergency, and the risk of it deploying accidentally in heavy weather. Whatever solution is chosen, for long passages it might be necessary to make other compromises to ensure that the liferaft is located in the best possible position to ensure its availability in the event of a catastrophic event, such as a sudden capsize.
The Marine Accident Investigation Branch has:
- During the investigation, made the following recommendation to the RYA, which the RYA has accepted:
2014/159 Bring to the attention of its instructors, examiners and other members, the risk posed to yachts of keel failure as a consequence of structural weakening that can occur as a result of repeated minor groundings.
- Issued a Flyer to the Leisure Industry (Annex L).
The Maritime and Coastguard Agency has:
- Undertaken to work with the Royal Yachting Association to clarify the requirements for the stowage of inflatable liferafts on coded vessels for inclusion in new workboat and non-workboat codes.
The Royal Yachting Association has:
- Drafted enhancements to its Sea Survival Handbook at the next reprint. These advise that in the event of a keel failure a yacht’s rapid capsize and inversion is possible, outline the potential cause of keel failure and how it can be avoided, and suggest actions that can be taken when there is concern over the security of a keel.
Stormforce Coaching has:
- Made the following changes to its internal policies/taken the following action:
- All staff and crew on races or motor/sail training courses who travel more than 60 miles from a safe haven are required to carry a PLB.
- An external professional weather forecaster and router is to be engaged for ocean passages.
- In addition to regular visual inspections and inspection following a grounding, all ocean-going yachts are to undergo an annual third-party external survey.
- Unless participating in a race, yachts on ocean passages are to endeavour to sail in close company with another yacht, with skippers establishing a formal reporting schedule prior to departure.
- Liferaft stowage locations on all newly acquired yachts that will spend extended periods more than 60 miles from a safe haven are to be reviewed to ensure that the liferaft can be launched in the event of an inversion.
- Where appropriate stowage is available, existing 12-person capacity liferafts on yachts capable of venturing offshore are to be replaced with two 6-person capacity liferafts.
- Rudders on sailing yachts capable of venturing offshore are to be painted day-glow orange to assist with their location in the event of an inversion.
- Lifejackets with retrofitted spray hoods carried on yachts that are likely to venture more than 60 miles from a safe haven have been replaced with new 190N lifejackets fitted with an integral spray hood.
- A second EPIRB in a float-free location has been fitted on yachts that are likely to venture more than 60 miles from a safe haven.
- All fleet maintenance reporting, recording and planning are now managed using online cloud-based software.
- An ‘out of the water hull inspection’ policy is now documented in the company’s operations manual.
The British Marine Federation has:
- Submitted a suggestion for discussion at the next systematic review of ISO 10240 (Small Craft-Owner’s manual) to the effect that the Owner’s Manual should state that, in the case of a grounding, a full assessment/survey needs to be completed.