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Originally Posted by John Kennett
I've just read the MAIB report, and it's clear that the thread title (although provoking debate) is by no means an accurate summary of this incident.
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agreed the lifejacket didn't cause the accident, it just, probably, impeded the cadets ability to rescue herself.
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The type of lifejacket was just one of several failings:
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yes - and the MAIB always highlight everything they find wrong even if it is not directly relevant. In some ways that helps paint a picture of the environmnet/situation but it is also quite distracting.
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• The lack of a risk assessment specific to the activity conducted
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yes although not recorded someone did make some sort of risk assessment - the transport by sea was only to proceed subject to weather, the skippers discussed the weather and agreed to go, and the fact that everyone was wearing a LJ means there were, perhaps subconsciously, identified risks.
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• The failure to implement control measures detailed on the generic risk assessment such as the provision of a safety boat and the fitting of propeller guards
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I am not sure many people would have identified a separate safety boat as a requirement for transport across water, especially with 3 boats in the fleet. Prop gaurds would not have impacted on this specific incident.
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• The lack of safety orders for training on water
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I wonder if this transportation trip was viewed "as training" or even being particulalry high risk - its purpose was to move the personnel from one location to another. Had the accident been in an old army minibus/truck on a windy road would the same level of criticism be levelled?
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• The use of lifejackets unsuitable for children and civilians
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• The lack of communications with shore personnel
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agreed. And it may well have been appropriate to file a passage plan with the CG although not mentioned by the MAIB. Time was wasted after the first Mayday call as wrong location was given.
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• The failure to keep a record of persons on the water
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absolutely. This was probably the cause of death. The lesson to all RibNet skippers should be - know how many people are on your boat and if the preverbial does hit the fan make sure they are carefully counted. But actually with 11 identically dressed people in the water I suspect it is easier to make a mistake than we think.
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• The lack of provision for non-swimmers
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but had no bearing on this incident.
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• The lack of awareness of all of the coxswains with regard to the intended passage plan
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or actually the complete lack of any real passage plan.
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• The number of persons on board the RRC2
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but the report also acknowledged that whilst there was one person over the official loading the boat was not overloaded (as smaller people/less kit carried).
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• The condition of the RRCs and the equipment carried (engine configuration, the lack of nautical charts and other navigational equipment, the condition of flares and fire extinguishers and the lack of navigation lights on one of the craft).
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nav lights and fire extinguishers had no bearing on this incident; nobody attempted to use a flare so that has no bearing either. The MAIB think that if a chart had been carried it would have resulted in a better distress call. I suspect the person who wrote that has never had to make a distress call in a genuine emergency with 11 people in the water.
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There's plenty to be learned from this report though. It's worth everyone reading it and thinking about their personal risk assessments and emergency plans.
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Agreed - and how you account for people after an incident. If it does ever happen it would be worth counting them both as soon as possible and as soon as landed ashore.