High speed pass: fatal disaster

On the evening of 25 May 2019, at sea in the vicinity of Cannes, the Yacht Vision was under the command of an unqualified master who was a regular, if moderate, of cannabis. Influenced by charter party requests, he attempted a very high speed pass of the anchored yacht Minx. The attempt failed, and Vision collided with Minx at a speed in excess of 30 knots. A newly recruited crew member, on their first day serving at sea on Minx, was fatally injured.

Manoeuvring vessels in close proximity at high speed is one of the most skilled tasks that a mariner can preform. Even when only one vessel is in motion the successful execution of high speed work requires careful preparation, currency in their execution, and a certain method of safely exiting the scenario should matters develop in an unfavourable way. It is difficult to conceive that the conducting high speed manoeuvres close to over vessels for the entertainment of passengers could ever be justified.

Reports into incidents, especially human factors incidents, are often not easy reading. In few reports concerning essentially simple situations are quite so many opportunities for avoiding the disastrous incident avoided. It is always tempting to assign blame to a single individual: the ‘bad apple theory’. This usually a mistake; since very often it is the systems behind the apparently responsible person which enable and permit incidents. So looking behind the tragic rage, what factors and systems might be of interest.

The master of Vision was unqualified

While the master was experienced, he was operating the vessel on the basis of a RYA Yachtmaster Offshore (Power) certificate that had not been Commercially Endorsed. He was therefore unqualified to be in charge of the 78gt, 23.96m yacht. Testing the hypothesis that ‘Vision was not the only vessel being operated using a certificate that was not appropriately Commercially Endorsed is a straightforward and suitable way to examine whether this commander is indeed a ‘bad apple’ or whether there is a rotten orchard at hand.

Why had the responsible parties not determined the lack of suitable qualification?

The owner of Vision, in the case of this incident also the charter party, had the responsibility for ensuring the master was qualified. Further in the period since the master had been appointed, Vision had been surveyed on behalf of the Gibraltar Maritime Administration on 28 February 2019 and issued with a SCV code certificate valid until 17 December 2019. At least two opportunities to determine the masters ineligibility for commercial command had been missed. First the owner or owner’s agent had appointed the master, secondly the Surveyor had not highlighted this serious deficiency. Did the master’s perceived experience with this type of vessel blind investigators to his ineligibility? Are Surveyors consciously or subconsciously concerned that reporting deficiencies to owners may pose a commercial threat to their operation?

 The vessel was complex and marginally within the code parameters

Vision was being operated under the Maritime and Coastguard Small Craft Code which is applicable to vessels less than 24m. The ‘SCV Small Craft Code’ provisions have undoubted advantages to commercial operators of smaller work and pleasure craft. In this case the length of the vessel suggests that she may have been ‘designed up’ to the code, which is not in anyway necessarily an illegitimate thing to do. However her statistics indicate that she was a very powerful craft, and the choice of a surface piercing combined propulsion and steering system endowed her with complex propulsion characteristics.
A human factors question would be , and if so to what degree, designers are producing plans for vessels that are significantly more complex in terms of propulsion, subsystems, hydrodynamics and seakeeping than was envisaged when the SCV Code was last reviewed. If this was occurring it might point to unwitting regulatory capture by yacht builder.

There were pertinent operational deficiencies

The instruments indicating the trim of the Yacht Vision with regard to her propellors was not reliable. Because of the surface piercing propulsor type, this was potentially critical since knowing the hydrodynamic characteristics of the vessel and the propulsory depend critically on understanding the changes in this trim. There is a more technical discussion in the MAIB report, but suffice it to say that without this information it would be difficult to predict exactly how and at what rate the vessel would turn. The neglect of the repair of a important system like this is deeply concerning and may raise serious questions about the way people were controlling the maintenance of Vision.

The power gradient between Owner, Charterers, and Master.

In this case the yacht Vison was being chartered by the beneficial owner of the corporation that owned the vessel. It is apparent from the account of the hours before the incident that the Master was at risk of being excessively influenced by the charterers and potentially neglected the safety of the ship and her passengers. We expect the masters of yachts and other vessels to be competent navigators. In this case however there was also a need for the Master to be an astute navigation of the complex power gradients in play among the passengers. From a Human Factors perspective it would be important to understand the degree to which large yacht crew are professionally equipped to manage the complexity of the that power gradient.

The Master was a regular user of Marijuana or some Cannabinoid derivative.

The literature on the negative impact of Cannabinoids on human performance continues to grow. Driving might be considered a proxy for the complex series of tasks involved in manoeuvring a boat. There is now evidence from cross sectional public health studies on the association between cannabis and skilled tasks such as driving, indicates that after controlling for age, sex and driving record the presence of cannabis in a driver’s system was associated with a higher risk of a potentially unsafe driving action. What is unknown and remains un-investigated is the prevalence of Cannabis use among commercial yacht skippers. If the prevalence is signifiant it would useful to understand why some commercial yacht mariners consume Cannabis is moderate quantities.

The loss of life on the Yacht Minx

The Yacht Vision struck Minx a glancing blow infecting considerable damage to her foredeck. The newly recruited foredeck hand was at sea on on Minx for the first time. As an anchored vessel Minx could not avoid the out of control Vision. The only comment that can be made is that when a vessel is manoeuvring at high speed, or in a manner which suggests less than perfect control, it is probably wise to consider where crew and passengers are, and whether there are any actions; such as clearing the upper deck, which can be taken to protect all on board.

This blog is based on Accident Investigation Report 1/2021 from the Marine Accident Investigation Board which is Crown Copyright, local media reporting, and commentary in the Maritime press. The presence of a question about a systems issue behind this VSMC in this blog is not to be taken as an indication or implication that an issue was a contributing factor to the collision between these two yachts.