Fatal Storm (38 page)

One crucial lesson that came out of the 1998 race was
the fact that if all participants had been carrying the now mandatory digital 406 MHz distress beacons, it would have given the Rescue Coordination Centre staff a clearer picture of what was happening out at sea. The 121.5 MHz analogue system only served to confuse both operators and searchers.

In the past three years AMSA has also contracted five purpose-built aircraft positioned in Darwin, Perth, Essendon, Brisbane and Cairns for dedicated use on search and rescue operations. These aircraft are an enhancement to the contracted aircraft AMSA already has access to around Australia.

AMSA has also implemented Self Locating Datum Marker buoys for drift calculations. The Argos satellite system is used to provide hourly updates on the position of the drift buoys to the ERC.

T
he Report from the NSW State Coroner, Mr John Abernathy, following his inquest into the deaths of John William Dean, Michael Bannister, James Michael Lawler, Glyn Roderick Charles, Phillip Raymond Charles Skeggs and Bruce Raymond Guy during the 1998 Sydney to Hobart Yacht Race.

The Coroner released his report on December 12, 2000. It was a 341-page document. This abridged version of that report details his findings on some of the major issues associated with the tragedy.

…the inquest is a most positive process and the driving force behind this inquest, apart from determining just how each of these men met their deaths, was the desire to consider whether or not constructive recommendations could be made in order to help maximise the chances that a similar disaster will never occur again.

In this regard, there is no doubt at all that the Cruising Yacht Club of Australia has taken this tragedy very seriously indeed, and in the time that has elapsed, not only conducted its own detailed investigation, but made many innovative changes which in turn have made the running of this race much safer for its contestants.
Some of these changes inflicted, as it were, on contestants have not been well received by a few, as being so draconian that an element of the “sport” of yachting has been taken away. On the whole I view the changes already made as both desirable and necessary. The yachting movement cannot afford another disaster of the magnitude of this one.

It is axiomatic that the examination of the 1998 race by the CYCA has to a large extent rendered nugatory the need for me to make a large number of recommendations pursuant to Section 22a,
Coroners Act 1980.
That in itself is a positive incident of this disaster.

In general terms the sterling and often heroic work of those involved in search and rescue from the under populated South Coast of New South Wales and the East Coast of Victoria underscored that volunteers, by taking to the sea and the air, are prepared to put their own lives on the line in attempting to rescue others. The changes to the running of this race since 1998 will greatly lessen the risk to these courageous men and women.

My recommendations apply to all Category One [Ed note: An offshore racing safety category.] races which take place within the jurisdiction of this Court.

My formal recommendations are: –

1. That all crew members of competing yachts wear a personal EPIRB (Emergency Position Indicating Radio beacon) when on deck in all weather conditions.
   
2. That all crew members of competing yachts be trained in the use of personal EPIRBS.
   
3. That all competing yachts carry on board a 406mhz EPIRB and not a 121.5mhz EPIRB.
   
4. That all inflatable liferafts carried on board competing yachts should comply with the construction requirements of regulation 15 of the International Convention of the Safety of Lives at Sea 1960 (“SOLAS”).
   
5. That the contents of the inflatable liferafts carried by competing yachts be as follows:
   

Each raft shall have at least the following equipment, properly stowed and secured so as to be available undamaged after launching and inflating.

1. One sea anchor or drogue (the attachment line should not be less than 15 metres) attached so that the entry point to the raft is leeward (the NMI – Pattern with anti-tangle lines is recommended).
   
2. One safety knife.
   
3. One bellows or hand pump for hand inflation. (That is of one piece, ready for use and does not require assembling.)
   
4. One waterproof torch (signalling). (Together with one spare set of batteries and one spare bulb in a waterproof container.)
   
5. One heliograph.
   
6. One bailer. (Easily identifiable as a bailer.)
   
7. One sponge per person.
   
8. One repair outfit capable of repairing punctures in buoyancy compartments. (When such buoyancy compartments are wet with salt or fresh water.)
   
9. Six emergency buoyancy tube leak stopping plugs.
   
10. One buoyant rescue quoit attached to at least 30 metres of buoyant line.
    
11. Four red hand-flares and two smoke signals or combination of both.
    
12. Two red parachute flares. (Of an approved type capable of giving a bright red light at a high altitude.)
    
13. One signalling whistle.
    
14. Sufficient drinking water, giving 0.5 litres per person.
    
15. One tin of emergency rations per person.
    
16. Two tubes of sunburn cream.
    
17. Five plastic bags, not less than 450mm x 300mm per person.
    
18. An operational instruction card
    clearly legible
    on the liferaft and its contents, waterproofed or stencilled on the inside of the canopy (and on the inside of the buoyancy compartments).
    
19. A USL Coastal Pack First Aid Kit.
    
20. A water maker is recommended for long Category 1 and 2 Races.
    
21. Two conventional paddles.
    
22. One set of fishing tackle.
    
23. Six anti-seasickness tablets for each person the liferaft is deemed to accommodate.
    
24. One waterproof copy of the illustrated table of life-saving signals referred to in Regulation 16 of Chapter V of SOLAS.
    
25. One waterproof copy on how to survive in the liferaft.
    

6. That weather forecasts which are specifically provided for yacht racing fleets contain:-

1. As well as the average winds expected, the maximum gusts of wind that are likely to occur; and
   
2. As well as the significant wave heights expected, the maximum wave heights that are likely to be encountered.
   

7. That all yachts’ batteries be of the closed or gel cell type.

8. That competing yacht crew who are on deck during
rough weather should wear clothing that will protect them from hypothermia.

9. That competing yacht crews use personal flotation devices (PFD’s) other than the “Mae West” type.

10. That all crew members of competing yachts have with them a personal strobe light when on deck in all weather conditions.

11. That each competing yacht carry on its hull or deck some form of marking that can readily identify the yacht to air rescuers.

12. That at least 50% of a competing yacht’s crew should have completed a yacht safety and survival course every three (3) years: –

1. That such yacht safety and survival course be the course ABF511 of the Australian National Training Authority; and
   
2. That such yacht safety and survival course be taught by instructors who hold a current Australian National Training Authority Certificate for Assessment and Workplace Training BSZ40198.
   

The following recommendations are not made to the CYCA and the AYF.

13. That Workcover New South Wales inquires into, and reports to the relevant minister of the Crown, on the practices aboard racing yachts of providing “payment” to some crew, and the ramifications which may flow from that practice.

14a. That the Minister for Fair Trading (NSW) or other relevant NSW government minister considers ordering the withdrawal from the market of all harnesses and lanyards bearing the name “Tuff Marine Australia” or any derivation of that name.

The said minister or other relevant NSW government minister considers requiring that all harnesses used by yacht crews have a crotch strap fitted; and

16. That the said minister or other relevant NSW government minister considers pursuing a review of Australian Standard AS2227.

a. The Race Committee

The Race Committee comprised not only CYCA members but also members of the Royal Yacht Club of Tasmania (“RYCT”).

The following comprised the Race Committee

• Hans Sommer (CYCA Vice Commodore) – Chairman
  
• Howard Elliott (CYCA Member)
  
• Robert Badenach (RYCT Immediate Past Commodore)
  
• David Boyes (RYCT Commodore)
  
• Bruce Rowley (CYCA General manager)
  
• Mark Robinson (CYCA Sailing Administrator)
  
• Phil Thompson (CYCA Sailing Manager)
  

Of the above Messrs Rowley, Robinson and Thompson were full-time employees of the CYCA. Of these Robinson and Thompson were involved in the Race administration, whilst Rowley was the Club’s General manager and played no part in Race organisation.

In essence the Race was administered on a day to day basis by Phillip Thompson who, as the CYCA Sailing Manager, had his normal working area in the CYCA Sailing Office. Mark Robinson…also worked in the Sailing Office under the control of and answerable to Phillip Thompson.

1. The Sydney to Hobart Yacht Race is a Category 1 Race according to the AYF’s (Australian Yachting Federation) Racing Rules of Sailing.
   
2. Category 1 races require a limit of positive stability of 115 degrees or greater. (Though this had been modified under a “grandfathering clause” by the CYCA. That allowed yachts that had previously sailed in the Race, to enter if their limit of positive stability was 110 degrees or greater). Thus a yacht could withstand being rolled to 115 degrees by seas and recover its upright position.
   

The
Naiad
should, at the very least, have had a limit of positive stability of 110 degrees to be accepted into the Race. Its current IMS Certificate showed its limit of positive stability as 104.7 degrees. She was therefore clearly ineligible to race under this Certificate.

Mr Dunda was the Shift Supervisor at the Bureau of Meteorology (BOM) Sydney offices from 7am to 7.30pm on 26 December 1998. He was Messrs (Ken) Batt and (Brett) Gage’s Supervisor. He would have reported to the BOM Regional Director.

It was Mr Dunda who formulated the wording for the “Storm Warning” that was issued at 2.14pm (1414 hours) that day.

I find the evidence of Mr Dunda, considering the position that he held on the day, to be vague to say the least. Clearly the BOM had no legal obligation pursuant to contract, to contact the race organisers, but if one accepts the evidence of Batt’s concern [Ed note: This
relates to Mr Batt’s evidence about his concern for getting the storm warning information to the CYCA.] (and it does not just come from Mr Batt), one wonders why that option was not discussed, even if then discarded.

Going back to the 14:50 forecast the words:-

“WARNING: Storm Warning is current south from Merimbula.”

These words should have alerted Mr Thompson that from Merimbula south, that is just north of Eden, the fleet would encounter winds of at least 47 knots and gusts that could reach up to 66 knots.

The fact that he says:-

“I did not read any forecasts which struck me as being unusual or alarming for a Sydney to Hobart Race.”

And at page 22 of that statement says:-

“At the time of preparing this statement, I read the 14:50 forecast and I am still of the view it contains nothing of particular concern.”

is confirmation that he did not and still does not understand the gravity of what the forecast means.

For a man who was occupying the position of Race Director and to whom the other members of the CYCA Race Management Team deferred, this lack of understanding then and now is of the gravest concern.

Clearly Mr Batt and Mr Gage by making a series of prompt notifications could see the seriousness of the situation.

This obvious urgency that the CYCA “needed to know” that the situation in Bass Straight [sic] in 18 to 24 hours would be bad, was not, however, shared by their senior officer, Mr Dunda.

The fact that after approximately 3pm on 26 December no member of the BOM again sought to
convey this “need to know” has not been satisfactorily explained to this inquest. Nor can the “protocol” that “the onus has always been on the CYC to contact us” provide an explanation.

[Later in this section of his report, Mr Abernathy said:]

It is clear to me…from all that I have heard and read that the Race Fleet required information on the weather conditions from the early morning of 27 December. The Race Management Team failed to provide this.

[Ed note: Mr Abernathy said that during the “critical period” from when the disaster began to unfold on the afternoon of December 27, “the Race Management Team did no more than adopt a ‘wait and see’ approach and effectively abdicated their responsibility to manage the Race.“]

1. …I find that despite the initial sense of urgency that both men (Ken Batt and Brett Gage) displayed in seeking to alert the CYCA with their telephone calls, this urgency:-
   
   1. Was not shared by their immediate Supervisor, Mr Peter Dunda; and
      
   2. After the initial telephone calls no further attempt was made by them or any other officer of the BOM to contact the CYCA.
      

It is this part of the evidence given on behalf of the BOM that remains perplexing.

Why no-one at the CYCA was contacted after the initial attempts by Batt and Gage cannot be explained away with glib statements such as:-

“…I followed all policies and procedures in issuing that warning…” (Dunda transcript 20 March 2000)

3. I find that Mr Phillip Thompson, Mr Mark Robinson and Mr Howard Elliott, who formed the CYCA Race Management Team, did not fully understand the formulae used by the BOM in its forecasts. By which wind speed and wave height are to be interpreted.