Report on the investigation of the. Deaths of. Helm. and. Crew. during Club Racing on. 12 th July Kielder Water Sailing Club

Transcription

1 Report on te investigation of te Deats of Helm and Crew during Club Racing on 12 t July 2009 at Kielder Water Sailing Club Royal Yacting Association RYA House Ensign Way Hamble Soutampton SO31 4YA Report Date 14/08/2009 1

2 Tis investigation as te sole purpose of ascertaining te causes and circumstances of te accident wit te intention of prevention of future accidents werever possible. Tis report is not written wit litigation in mind. 2

3 Contents Page Glossary of Abbreviations and Acronyms 4 Synopsis 5 Section 1 Factual Information 6 Particulars of te Boat and Accident Persons involved Personal Protective Equipment Sailing Experience of tose involved Narrative Weater Section 2 Analysis 12 Section 3 Conclusions 14 Section 4 Actions Taken 16 Section 5 Recommendations 17 Appendices 17 Appendix 1 Ordnance Survey Map of Kielder water 18 Appendix 2 Kielder Water Sailing Club Year Book extracts 19 Appendix 3 Qualifications and training records 28 Appendix 4 Details of patrol boat and engine 29 Appendix 5 Laser Stratos RCD information 30 3

4 GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS 50 NEWTON BUOYANCY AID - CE Approved Buoyancy Aid designed for tose wo can swim and wo are close to elp AVS - Angle of Vanising Stability BEAT - Te upwind leg of a course were boats are sailing close auled CAPSIZE - To overturn or cause to overturn: Te boat capsized CENTRE SHEETED - Seeting arrangement for te main seet. CENTREBOARD - A centre board is a form of movable keel on a sailboat located on te bottom of te ull along te centreline CLOSE HAULED - A point of sailing were sails are pulled in tigt and te boat is sailing as near to te wind direction as is possible COMMITTEE BOAT - Te vessel controlling dingy racing CREW - Person wo controls spinnaker, jib etc in a sailing dingy DINGHY - A small ligtweigt sailing boat wic relies on te crew weigt to give stability. FORESTAY - A piece of standing rigging wic stops a mast from falling backwards GENNAKER - A large asymmetric spinnaker wic as similar control lines to a jib GUNWALE - Te outer edge of a boat were te ull joins te deck. HELM - Person wo steers a boat INVERSION - A complete 180 degree capsize JIB SHEET - Te controlling line on te foresail of a sailing boat KICKING STRAP - A mecanism wic prevents te boom of a sailing boat from rising up KWSC - Kielder Water Sailing Club LASER STRATOS - A class of family sailing dingy also popular wit sailing scools LEEWARD - Downwind LOA - Lengt Over All LOWER SHROUD - Te lower lateral support for a mast MAIB - Marine Accident Investigation Branc of te DfT MAIN SHEET - Te rope controlling te main sail MAINSAIL - Te sail aft of te main mast MCA - Maritime Coastguard Agency NW - Nort West PATROL BOAT - A vessel used to assist or elp te race officer and vessels competing in racing PRO - Principal Race Officer QRTH - Quick Release Trapeze Harness RIB - Rigid Inflatable Boat RIGGING - Te wires olding up te mast RO - Race officer in carge of starting, recording and finising a race RUDDER - Te device used to steer a boat RYA - Royal Yacting Association SAIL NUMBER - Te unique number on a racing boat wic identifies it to oter competitors and to race organisers SELF DRAINING - A design of dingy wic does not retain water after a capsize SHROUD - Te lateral support wire for a mast SLOOP RIGGED - A fore and aft rigged vessel SPINNAKER - Te large downwind sail at te front of a sailing boat SPINNAKER SHEET - Te controlling lines for a spinnaker SPRAY TOP - A water proof top worn on te upper body STERN - Te back of a vessel TRAPEZE HARNESS - Te arness wic allows te crew to attac to a trapeze wire by means of a ook TRAPEZE HOOK - A ook wic attaces to te lower fitting of a trapeze wire TRAPEZE WIRE - A wire attaced to te mast of a sailing dingy from wic te crew or elm is attaced to allow crew weigt to be moved furter outboard VHF - Very Hig Frequency radio WETSUIT - An expanded neoprene termal garment used for water sports WINDWARD - Upwind WINDWARD LEG - An upwind leg of a race course used in dingy and yact racing 4

5 Synopsis Kielder Water Sailing Club At approximately 1500 rs BST on te afternoon of Sunday 12 t July 2009 two competitors were involved in a capsize and subsequently died wilst taking part in a series of dingy sailing races organised by Kielder Water Sailing Club (KWSC) in Nortumberland. Te Kielder Collection, a five race series, was part of a regular racing programme organised by te club for its members. Te sailing dingy capsized during a gust of wind and te crew was caugt in te rigging and dragged under te water by te weigt of te inverting boat. Te elm died wilst attempting to release te crew from te boat. Te sailing dingy involved in te incident was a Laser Stratos Sailing Dingy, a two person family dingy wit main sail, jib and asymmetric spinnaker. Te dingy was also fitted wit a trapeze. Several factors contributed to te accident. Te capsize and rapid inversion of te dingy Te trapeze wires of te dingy Gusty wind conditions 5

6 Section 1 Factual Information Particulars of te sailing dingy and accident Vessel details Owner : Removed to protect confidentiality Type : Laser Stratos Dingy Design Category : RCD C Built : Laser Performance Station Works Long Buckby Nortampton NN6 7PF Purcase Date : 1999 Construction : GRP Lengt overall : 4.94m Beam : 2.10m Draft : 1.20m Hull Weigt : 180 kg Sail Number : 132 Main sail area : sq m Jib Area : 3.51 sq m Spinnaker Area : sq m Hull Identification : HIN. GBR SEB number Maximum load or number of persons : 6 Persons Accident details Time and date : Approx 1500 BST, 12t July 2009 Location of incident : Lat N. Long W. Kielder Water Reservoir, Nortumberland Persons on board : 2 persons Injuries : 2 Fatalities Damage : Distortion to te port and trapeze wire 6

7 Personal Protective Cloting Bot elm and crew were well equipped wit spray top, wetsuit, wetsuit boots, CE Approved 50N buoyancy aid, gloves, knife, and wistle and in te case of te crew, a quick release trapeze arness. Crew Helm Picture of elm spray top unavailable 7

8 Personal Sailing Experience Helm Te Helm and is family ad been members of KWSC for many years. He ad taken part in various RYA sail training courses during tis time including an RYA Level 3 course in 2001 and subsequently RYA Advanced module courses in Seamansip Skills, Start Racing and Sailing wit Spinnakers (in is asymmetric rigged Laser Stratos) Te Helm was also a keen rower and was tus confident on and in te water. Te Helm took part in club racing, usually in is Stratos dingy, wit members of is family as crew and in 2007 won te 'Novice Series' a popular tropy series in te club. (A novice at KWSC is regarded as anyone wo as not managed a 1st, 2nd or 3rd overall in a normal KWSC race series). Many club members are eligible. Te elm completed an RYA Power Boat Level 2 course on 22nd February Crew Te Crew ad completed several RYA Yout Sailing Sceme Courses at KWSC as a junior including Stage 1 and 2 and sailed mainly wit er family members in te Stratos or occasionally in oter club boats. Se ad also sailed a 420 (a two person trapeze dingy) in 2007 wit a friend. Te crew ad sailed wit te elm in te Stratos bot cruising and racing from time to time. Te crew was described as a relatively inexperienced sailor but by no means a beginner. Weater Te weater on te 12 t July 2009 at Kielder Water was westerly force 3-4 wit occasional stronger gusts. Te wind was described as sifty varying in direction up to 10 degrees eiter side of a mean direction. Tere ad been some precipitation during te day. Te waves were described as coppy and sligtly confused. Weater forecast for - Newcastle, Lat: 54.21, Lon: -5.89, Time zone: GMT+ GFS Wind speed (knots) Wind direction Temperature ( C) Rain (mm/3) Cloud cover (%)

9 Narrative Kielder Water Sailing Club (KWSC) is a private unincorporated members sailing club run by volunteers and affiliated to te RYA. Te club is also an RYA Recognised Training Centre. KWSC organises a variety of sailing activities during te year ranging from learn to sail courses for adults and cildren to more informal cruising and a regular and a varied racing programme. It was during one of te clubs race days tat te incident occurred. Te incident occurred during on te second upwind leg of race 4 of a five race series taking place on te 12 t July 2009 called te Kielder Collection. Tere were twelve boats taking part in mixed andicap fleet racing ranging from a Musto Skiff, Osprey, Supernova, Laser, Topper, Comet, Miracle, Wayfarer, Laser Stratos and Flying Fifteen. Te incident involved a Laser Stratos Dingy, a two person family dingy wit mainsail, jib and asymmetric spinnaker. Tis particular Stratos also ad a single trapeze system fitted wic te crew, ad been seen to be using upwind in te stronger breeze of te day but not on te downwind legs. Te Crew was wearing a quick release trapeze arness wit ook manufactured by SeaSure Ltd. Te Race Officer, sceduled for te day, ad not turned up and it was terefore agreed tat different sailors from te racing fleet would sare te role of Race Officer between tem for eac race of te series. During race 4, te second race of te afternoon te race officer set a trapezoidal course using marks 12, 2, 4, 6 and te start/finis line located in te centre of te course area. Te approximate diameter of te race course is 850 metres. See diagram below. KWSC committee boat and start/finis line Approx location of incident. Race 4 began at approximately 1430rs and te Laser Stratos completed te first upwind leg to mark 12 witout incident. Te Helm and Crew of te Stratos ad ad a reef in teir mainsail during te first races of te series but tey ad removed te reef for te afternoons racing. Tey were observed to ave ad a sligt problem oisting te spinnaker between mark 12 and mark 2 during race 4 but tis was 9

10 obviously sorted quickly as te boat ad fully oisted te spinnaker before reacing mark 2. On examination of te boat on Monday, it would appear tat tis problem may ave been caused by a paddle being placed in between te oisting lines for te pole and alyard. Noting furter was observed of te Stratos during te remainder of teir first lap and te pair passed troug te start finis line to begin teir second lap upwind. Tey would ave been lapped by te faster boats in te fleet suc as te Musto Skiff and te Osprey, wo were now beginning teir tird lap, wen cries were eard by te Race Officer and oters tat alerted tem to te capsize. Te Laser Stratos ad capsized on port tack wit te starboard side of te ull in te water towards mark 12 (te windward mark) of te course. Te Stratos was far enoug away tat te Race Officer could not see any detail of te capsized boat and its occupants and unfortunately no oter witnesses saw te actual moment of capsize. A witness in is Musto Skiff stated tat e could see te Helm trying to support is Crew in te water wilst souting for elp. Te Race Officer could also see te elm and crew splasing in te water in te vicinity of te mast and rig and eard bot cries for elp. Te Race Officer radioed immediately for te Patrol Boat (P1) to attend. P1 ad just ad been attending te breakdown of Patrol Boat 5 (P5) on te eadland near to te club slipway and ad towed tem back to te club jetty wen te radio call came in. P1 set off towards te incident from te club jetty wic was some 500/600 metres distant. Te patrol boat, sown below, a Ribcraft 4.6m wit a 50HP engine, ad a coxswain and crew onboard and it is estimated tat it would ave taken approximately between seconds at a speed of 20/25 knots to reac te incident. Patrol boat P5 Patrol boat P1 On arriving at te incident P1 s occupants, (referred to as Patrol Crew 1 & Patrol Crew 2), found te Stratos completely inverted and no sailors visible. Patrol Crew 2, radioed te Committee boat to ask if tey ad been taken off but te reply came 10

11 back tat tis was not te case and tey could be under te upturned boat. At tis point Patrol Crew 1 entered te water and swam te sort distance to te dingy and called in troug te centreboard slot to try and locate te occupants. Te centreboard was found to be retracted into te ull at tis stage. A furter conversation by radio occurred between te Race Officer and Patrol Crew 2 in P1 and e went to collect te race officer wo ad by now abandoned racing by flag and sound signal. Te Race Officer was taken to te upturned ull to elp of Patrol Crew 1 in rigting te Stratos. Patrol Crew 1 ad already partly raised te Stratos and wit te Race Officer s elp brougt te boat up far enoug tat te two bodies could now be seen. Tis task was made more difficult by te centreboard being retracted into te ull. Te Race Officer and Patrol Crew 1 ten swam around te boat to discover two bodies floating. Te Helm was closest to te inside of te ull and in te region of te crew area, ead towards te boat. Te Crew was in te vicinity of te spreaders and rigging. Bot were found face down in te water and unconscious. Patrol Crew 1 took te Helm in a life saving tow and swam wit im to te nearby waiting patrol boat were Patrol Crew 2 and Patrol Crew 1 raised im into te Rib and began CPR. Meanwile te Race Officer struggled to keep te Stratos Crew above water and realised tat er leg was caugt on someting and te weigt of te now sinking rig was pulling er down again. At tis point te crew of anoter sailing dingy, referred to as te Osprey Crew, was dropped close to te Stratos and swam over to elp. Te Osprey crew supported te Stratos Crew wilst te Race Officer returned to te ull of te capsized Stratos and after first putting te centreboard back down, swam around and climbed onto te centreboard to keep te boat in te orizontal or 90 degree position and prevent te boat re-inverting. Te Osprey Crew, seeing tat te Stratos Crew s leg was caugt on te trapeze wire, unclipped it from te mast wic enabled im to pull er free. Te Race Officer, wilst on te centreboard, radioed to te club for an ambulance. At tis stage te patrol boat P1 nosed in closer to te boat and te Osprey Crew, te Race Officer and Patrol Crew 2 pulled te Stratos Crew onboard P1 and began CPR. Te Stratos was abandoned and te patrol boat returned to te jetty at approx 6-8 knots due to te fact tat it could no longer reac planning speed because of te additional weigt of 6 persons on board in wet cloting. It was also discovered later during te investigation tat tere was some water inside te ull of te patrol boat. KWSC end of jetty KWSC Jetty 11

12 Te club, aving already been alerted of te situation by radio, ad called for an ambulance. Te call was received at 1508rs according to te emergency services log. Meanwile te journey back to te jetty by P1 probably took approx approximately 2-3 minutes even at teir reduced speed because te wind direction was suc tat te Stratos ad by now drifted downwind and terefore closer to te jetty reducing te distance to be covered. Te patrol boat outboard engine appeared to cut out on two occasions during te return trip but was restarted quickly. One witness asore commented tat P1 did not appear to ave slowed down at any time. On arrival at te jetty te two casualties were lifted out of te patrol boat and CPR continued on te jetty, were more room was available, wit te assistance of furter club members including a local GP. Te first ambulance arrived at approx 1528 according to te emergency services log. Te paramedics wo attended ad some difficulties using teir equipment in te outside conditions but te two causalities were finally taken to Newcastle General Hospital by two Air Ambulances. Te Stratos Helm was certified deceased at 1645 rs on Sunday 12 t July and wilst te Stratos Crew was placed on a life support macine tey later died on te afternoon of Tuesday te 14 t July. Sometime later, approximately 1600, te Laser Stratos was recovered from te water by te patrol boat. Te club members rigting te boat did not comment on any difficulty in rigting it owever approximately 26 gallons of water was emptied from te ull by te Police and Club members later tat afternoon. Te dingy trolley tyre punctured during recovery as a result of te weigt of water in te boat. Section 2 - Analysis Evidence Summary a. Witness statements largely agree regarding te sequence of events, location and actions of persons tereafter. However no witness actually saw te moment of capsize until cries alerted tem to it. Capsizes are common in dingy racing but it was te cries for elp from te Stratos tat alerted te race officer and oters tat someting was wrong and it was ten te Race Officer observed te splasing in te region of te rigging as well as te cries of bot Helm and Crew. A witness was also close enoug in is Musto Skiff to see te Stratos Helm trying to support is Crew in te water. b. Te patrol boat (P1) responded to te radio call for elp from te committee boat and covered te distance between te club jetty and capsize of approx 600 metres in between seconds. 12

13 c. Te casualties ad been sailing for some years and were suitably experienced for te club racing tey were engaged in on te day. Tey were fit and ad no ealt problems tat we ave been made aware of. Te family ad owned and sailed te boat for many years. d. Te weater on te day was not exceptional in any way. However te wind from te west was gusty and wind sifts of degrees may ave contributed to te initial capsize. e. Te course set for racing used an 850 m clock face course wit 12 pre laid marks to coose from. Te race committee boat would be at te centre of te clock face. A trapezoidal saped sequence of marks 12, 2, 4, 6 was selected and provided appropriate and suitable racing for te conditions. Tree races ad previously been completed during te day. f. Te Race Officer was in communication wit bot te club and te patrol boat by VHF radios. g. Te Stratos was approx 10 years old but was in reasonable condition. It ad recently been returned from a service were it was evident tat repair work ad been carried out on te ull deck join on te starboard side. Evidence from testing sowed te boat to be water tigt in te 90 capsize position on port tack but significant water ingress to te buoyancy cambers occurred during a full 180 inversion. Tis was measured as approximately 16 litres in 10 minutes. It is likely tat tis entered te buoyancy camber troug te ull deck joints along te gunwale and internal buoyancy camber joints. Te Stratos also carried a foam buoyancy insert in te ead of te mainsail wic is intended to slow down inversion. Tis buoyancy was sufficient to prevent inversion in te unmanned boat during testing.. Upon arrival at te scene te Patrol Boat crew found te centre board of te dingy retracted into te ull and it is unknown weter tis appened prior to or during te capsize. Tis made te job of rigting te dingy by te crew more difficult wit less leverage available to perform te task. It was noted tat te centreboard did not retract into te ull during subsequent testing. i. Patrol Boat 1 was generally in good condition, well equipped and suitable for te role of patrol boat. Te engine and boat were maintained bot by professional 13

14 service agents on an annual basis as well as by day to day maintenance carried out by te club bosun and assistant bosun (a qualified marine engineer). j. Te Patrol Boat crew and Race Officer were experienced and qualified for teir respective roles. Te race officer, was a qualified RYA Dingy Instructor wit Powerboat Level 2 certificate and Scottis Yout Squad sailing experience. Patrol Crew 1Patrol Crew 1Patrol Crew 1ad a Powerboat Level 2 certificate and first aid experience as being a swimming teacer. Patrol Crew 2Patrol Crew 2 ad Powerboat Level 2 and work place first aid training. DINGHY CREW 3 also ad first aid training as an RYA Level 2 Racing Coac and Powerboat instructor. k. CPR was given wen te casualties were brougt into te patrol boat and maintained, wit some difficulty, until arrival back at te jetty were a Doctor, oter club members and first aiders were able to continue until te ambulance personnel arrived. l. During testing te patrol boat and engine were found to be fully functioning and te cut out of te engine experienced on te return trip wit casualties on board could ave been caused by someone standing on te fuel line in te boat s ten crowded state, terefore restricting fuel supply to te engine. Also in testing tere was found to be some water in te ull void. Tis was probably due to two factors including te o ring on te drain bung being no longer present and a split cable gaiter. Te bosun described te engines as being previously very reliable m. Te club was able to call for emergency services elp via a land line. However one small problem occurred in tat te 999 call could not be made witout payment as it was a paypone. n. Te emergency services, bot ambulance and Air Ambulance, attended quickly toug some difficulty was experienced in use of teir monitoring equipment due to te ambient ligt conditions. o. Te Police were also contacted and were on scene quickly. Club members cooperated wit te police and provided statements as required. Section 3 - Conclusions a. Laser Stratos Hull Number GBR SEB was taking part in club racing at Kielder Water Sailing Club on July 12 t 2009 and ad just completed lap one of race four in a five race series. Te boat was it by a gust of wind and capsized to leeward wilst on port tack in approx position N, W. b. Te boat was being sailed by a 52 yr old male as te elm, and 17 year old female as crew. c. No witnesses actually saw te moment of capsize owever in all probability te Crew was trapezing at te time as se ad been seen to do tis on oter windward legs. It is likely tat wen a gust of wind it te boat it leaned over, capsized and se fell forwards onto te sail and/or rigging. Someow during te capsize er left leg/ankle became entangled in te port and trapeze wire. From te distortion to te trapeze wire and te bruising to er left ankle, a full turn around te ankle may ave occurred 14

15 d. Te Helm may also ave fallen or jumped forwards into te water and/or sail as e was seen in tis vicinity moments after te capsize. We do not know if e first went to te centreboard and ten subsequently went to te assistance of is Crew. e. Te Stratos would in normal circumstances ave remained in te 90 position due to te foam in te ead of te sail as was demonstrated during subsequent testing ad not Crew s and probably Helm s weigt not been exerting a downward force on te sail and rig. Tis weigt overcame te initial positive buoyancy of te foam and te boat reaced a point were te combined weigt of te now inclined boat and rig continued to take te boat to a full 180 inversion. f. Sortly after te capsize te Helm was seen trying to support is Crew in te water but te combined weigt of te boat and rig was too muc for im and se was dragged under water. Tere is little evidence to suggest te Helm was entrapped so we must assume tat e continued to support is Crew and died in is attempt to rescue er. g. Capsizes in dingy sailing and racing are a common occurrence and are usually resolved witout incident. Participation surveys indentify over 400,000 people wo sail regularly in small boats and dingies.. Te response time of te patrol boat crew was seconds after being radioed. Te Patrol boat ad previously been called away from te immediate area of te race course to attend te breakdown of P5 and tey were by te club jetty wen te radio call was eard. i. Tis response time was well witin tat expected of normal club racing and would ave been similar ad te patrol boat been positioned at oter points of te race course. Tere was terefore no contributory time delay in te patrol boat attending. j. On arrival te patrol crew assessed te situation and made te decision, as recommended by te RYA, to immediately rigt te dingy using crew weigt on te ull to lever te boat up from an inverted position to try and reac te entrapped crew. Researc as sown tis to be te quickest and most reliable metod of rigting inverted boats. Te patrol boat coxswain also went to get te race officer for additional elp. k. Te centreboard was found to be retracted into te ull wen te patrol boat arrived on scene but wen tis occurred is uncertain. It is likely tat tis slowed te rigting of te dingy during rescue but te overall response time of te patrol boat crew and subsequent rigting of te dingy were easily witin normal expectations of a club racing environment. 15

16 l. Te number of persons wit first aid qualified was good and appropriate CPR was administered at a rate of 30 compressions to 2 breats for eac casualty. Tis was not easily accomplised in te tigt confines of te patrol boat but te cycle was maintained until arrival at te club jetty were oter first aid trained members could also elp. m. Te engine on P1 cut out briefly on two occasions wen returning to te jetty but tis fault could not be repeated during te investigation. It is possible tat tis was caused by te fuel line being stepped or knelt upon by one of te six persons ten in te patrol boat. n. Te KWSC racing on te day was well organised wit appropriate and suitably equipped patrol boats attending in ratios well witin normal expectations. o. Te course set by te race officer was suitable for te conditions and te number of boats racing. p. Communications between te committee boat, patrol boats and race office asore were good using VHF radios. q. Response by te emergency services was, on tis occasion, good given te rural location of KWSC but delays ad previously been experienced by te visitor centre next to KWSC. r. Te inspection of te Stratos ull on Sunday 12 t by te Police sowed tat 26 gallons of water ad entered te buoyancy tanks during te ¾ our te boat ad remained afloat after te incident. Subsequent testing also sowed significant water ingress during inversion test but minimal ingress during te 90 capsize test. s. Tere is no evidence tat te water ingress delayed te time taken to rigt te boat or indeed contributed to te initial capsize as te boat ad not previously capsized during te day. t. Patrol Boat 1 ad taken water onboard during a previous reversing manoeuvre wic was slow to drain due to te small drain flap installed. A larger diameter drain trunk would ave elped in tis regard. u. Te Racing Rules of Sailing make it clear tat a boat is entirely responsible for er own safety, weter afloat or asore, and noting, weter in te Notice of Race or Sailing Instructions or anywere else reduces tis responsibility. However most clubs, including Kielder Water SC, consider it to be good practice to provide patrol boats during club racing. Section 4 - Actions Taken a. KWSC contacted te Ambulance and Police services and te Police ten contacted te MAIB. b. KWSC also tried to contact te RYA but only out of office and answer pone services were reaced. No messages were left. c. Te MAIB informed te RYA on te afternoon of te 12 t July tat an incident ad occurred and bot organisations sent staff to investigate te incident. d. KWSC was contacted late afternoon of Sunday 12 t by te RYA. e. Te boats and personal equipment involved in te incident were secured by Police and Club members for later inspection. 16

17 f. Te Police cecked for water in te ull of te Stratos before securing te boat on Sunday evening. g. Interviews wit all tose involved were conducted on 13 t 15 t July and statements taken. Potograps of te boats, equipment and site were taken.. Capsize tests and full inversion tests were carried out on te Stratos i. Personal protective cloting of bot casualties was examined j. RCD testing information for te Laser Stratos was provided by Laser Performance Ltd. k. Discussions between te MAIB and RYA were eld. l. A draft report as now been circulated to te Commodore of KWSC and te MAIB. m. Tests were conducted using a similar Stratos Dingy to determine it s AVS in fres water. Tis was found to be approximately 120 from vertical. Section 5 Recommendations a. Dingy sailors involved in a capsize sould always consider going straigt to te centre board or dagger board to prevent inversion and ten allow time and opportunity for any entrapment to be resolved by tose involved or by patrol boat crews. b. Entanglement in trapeze wires or associated elastic cordage as featured in several accidents and te RYA sould continue to warn te sailing public about te potential azards. c. Patrol boat crews sould consider practising ow to deal wit inversions and te recovery of casualties into te particular patrol boats operated by teir clubs. In addition to tis, patrol boat crews sould also consider ow tey migt best perform CPR in te restricted confines of teir club s patrol boats. d. Dingy sailors sould be encouraged to use centre board / dagger board elastic tie backs or tie downs or oter effective mecanism in addition to existing centre board brakes as a means of preventing Centre Board retraction during inversions. e. Te RYA sould review its training programmes to igligt te prevention of inversion as a priority during capsize drills. f. Te RYA sould continue to promote appropriate training in powerboat andling, safety boat andling and first aid to elp patrol boat crews respond in te event of an on water incident. g. Te RYA sould update information available to clubs regarding race management and organisation and promote tis on its web site and in its training courses. Appendices Appendix 1 Ordnance Survey Map of Kielder water 18 Appendix 2 Kielder Water Sailing Club Year Book extracts 19 Appendix 3 Qualifications and training records 28 Appendix 4 Details of patrol boat P1 and engine 29 Appendix 5 Laser Stratos RCD information 30 17

18 Appendix 1 - Kielder Water Reservoir 18

19 Appendix 2 - Kielder Water Sailing Club Year Book extracts KWSC Guidelines On te Water Unlike oter clubs in te region wo use inland waters, we are allowed to sail witout te provision of rescue cover. Members sailing in tese circumstances must terefore ensure tat tey and teir boats are capable of coping wit te prevailing conditions and tat tey comply wit te club and water autority rules. Tere is no rescue service. Kielder Water Club Code Read and comply wit te Nortumbrian Water Rules & Regulations. See te notice board in te club ouse. Do observe te rules of good seamansip. Observe te rules of rigt of way. Keep a good lookout see and be seen. Help anyone in distress, owever inconvenient to you. Watc for weater canges. Do not put oters into danger. Keep well clear of small boats. Some sailboarders spend a lot of time in te water, were tey may be almost invisible. Keep clear Do not be foolardy. Have some tougt for oters wo may ave to rescue YOU if you get into difficulties. Tere is NO official rescue service on Kielder Water, but tere is an unofficial one it consists of YOU, te Club Members and all oter users of te lake wo look out for eac oter. Observe te rules of personal floatation devices, wet suits and cloting. Hypotermia can kill. Stay wit your boat if you get into difficulties. It is surprisingly difficult to swim in roug water and you will not be seen if you try to swim to te sore. Te boat will drift to te sore. Adults are always responsible for teir own cildren. No one under 16 is allowed to be in sole carge of a boat on te water unless supervised. No one under 16 is allowed to be on Patrol, or to drive a motor boat. Always sign on and off te water. Tere is a board to use for tis on te back of te main clubouse door for cruising sailors. Racers sign on on te race entry seet and sign off on te declaration seet. Trainees are signed on and off by te Course Instructors. Tis is so tat Emergency Services will be able to account for everybody if a situation sould occur. It is in your interests to comply. 19

20 Buoyancy Aids Buoyancy Aids must be worn wile on te water and on te jetty. Wetsuits or drysuits must be worn before April and after September but do not count as buoyancy aids. REMEMBER, Kielder is a very deep and cold lake and it remains cold trougout te year. Swimming is not allowed. Hours Sailing is allowed only in te dayligt ours. Launcing Wen launcing leave trailers at te edges of te concrete were it will not inconvenience oter members. Keep te slipway clear. Jetty Do not leave dingies tied up to te jetty, as te patrol boats and keel boats need te space. Tere is plenty of good foresore on wic to beac tem and tey will be less likely to suffer damage. Wear a buoyancy aid to go on te jetty. Do not allow cildren to play on te jetty. Retrieving Wen retrieving boats from te water by car DO NOT use tow ropes to pull te boat up te wole slipway. Once te trailer is clear of te water, itc te trailer to te car before proceeding. Safety All boats must carry a towing line or long painter fixed to te boat and ave adequate means of bailing. Make sure you ave read te NW Rules & Regulations section relating to your craft. Ferry All craft sall keep clear of te Kielder Water Ferry and associated jetties and landing places. Te ferry sall be regarded as a vessel restricted in er ability to manoeuvre. Proibited and Restricted Areas (See map in clubouse or map on back cover) Te Dam. Tere are wite diamond marks on te nort and sout sore; do not cross tis transit line. Te valve tower is in tis area. Te Little Wickope Water Ski bay. Tere are wite diamond marks on te west and east sore; do not cross tis transit line. Te buoys of te slalom courses are fixed to an underwater mooring system wic can be damaged by propellers and deep keels. Wickope Moorings. Do not sail between te moorings at any time. Leaplis to Bull Crag bay: Water ski area wit slalom buoys. Plasetts to Quarry bay: Occasionally restricted to water skiers only. Wen ski boats are operating all oter craft must keep out of te area. Quarry spit: Beware te long slip of land extending from te quarry wic creates a low water area. Patrol Boats Tese boats are not pleasure craft, tey are on te water for a specific purpose. Wilst on duty eac boat sould be crewed by two people over te age of 16 years wo ave been trained in te andling of te boat and ow to effect a rescue. One or bot of te crew sould be suitably dressed and be prepared to enter te water to give assistance if required. Eac of te patrol boats is equipped wit a First Aid Kit, Survival Bags, Flares and a basic Tool Kit, tis is emergency equipment and sould not be removed from te boats. Do not disturb te peace wit excessive noise or was. 20

21 Te club runs Safety Boat Tecniques sessions and RYA Power Boat Level 2 courses so tat members can acquire te necessary skills. Club boats. Te club boats are Wayfarers, Comets, Fevas, Toppers and Optimists. Tese are primarily for use during training but can be used by members wen available. A contribution to club funds is required for te use of te Wayfarers, Comets and Fevas. Te Toppers and Oppies are free. Te log books MUST be filled in and payment made to te training team or at te Galley. Full details are at te clubouse. Member s Duties Every member as at least one duty to do during te year. (See te DutyMan web site for te club at ttp:// Te Programme contains details of te duties members are to undertake during te course of te year. A brief description of te duties and responsibilities are given below and tere are fuller instructions in te clubouse and also on te website for you to read in advance. If you still feel appreensive or unsure, feel free to ask any committee member for advice before or on te day. Officer Of te Day (OOD) Te OOD is in carge of all racing and safety related matters. Tere are race officer mentors for support. Arrive by 09:30am on race day. Open te race office. Get te radios out. Ensure patrol boats are briefed, ready and manned and in radio communication. Wear suitable clotes for manning te committee boat. Ceck wind speed and direction. Brief competitors, if appropriate. Ask patrol boat to lay extra marks, as required. Set te first course. Run te racing programme for te day. Record te results. Tidy up and lock up at te end. Tere are full instructions and advice in te race office and on te web site to read in advance. Patrol Boat Crews Arrive by 09:30am on race day. Take te patrol boats out of te garage. Obtain fuel from te fuel store. Put te boats on te water and make tem ready for use. Ensure kill cords are available and ceck teir operation. OOD will brief patrol crew on te events. Ceck radio operation wit te OOD. At least one of te crew sould be suitably dressed to enter te water to give assistance, if required. Keep te jetty as clear as possible for use by keel boats and patrol boats. Lay marks at te direction of te OOD. At te end of te day put away te boats, fuel and radios in a clean and tidy condition. Return all keys to store. During racing te Patrol boats are to be crewed and on te water for te duration of te race, until allowed to go asore by te OOD. Te crew sould maintain radio contact wit Race Control and take instructions from te OOD. Galley You must be in good ealt. Galley duties start at 10:00am and will terminate at te end of te event. You will be preparing and serving food and ot drinks as necessary. 21

22 Read te Food Hygiene Management System and complete te monitoring log. Decide on te menu. Tere are guidelines about wat is available and suggested menus posted in te galley. Get lunc orders in to determine quantities before 11:00. Prepare to serve from 12:30 onwards. At te end tally up te takings and leave tidy ready for a key older to close. Tere are full instructions in te galley. Dingy Park Additionally, we all carry responsibility for te dingy park. Please make sure te dingy park is kept clean and tidy and tat your boat is secure and tied down. Allocation of a space in te dingy park is te responsibility of te boat park Committee members. You migt not ave te same space as last year. Contact one of te team before you bring your boat to be allocated a space. Please remember it is YOUR responsibility to do your duties. We are very keen to ensure tat everyone takes teir turn and tus spread te load. If you cannot make te date tat as been allocated to you it is also YOUR responsibility to find someone wo will swap wit you. You can use te website forum and DutyMan to organise a swap. Write your canges on te list at te clubouse. KWSC - Club Racing 2009 Notice of Race and Sailing Instructions Notice of Race 1.0 Conditions of Entry 1.1 All paid up members of KWSC are welcome to participate in club racing. 1.2 In accordance wit standard club rules, boats must be covered by tird party indemnity insurance for 2,000, Competitors sould note tat KWSC implements te RYA Racing Carter and tat tey will be required to undertake to sail in compliance wit te Carter. 2.0 Programme of Races 2.1 Te Sailing Programme is issued to members at te start of te season, posted on te club notice board, publised in te Year Book and te Club s web site. 2.2 Canges to te programme will be posted on te club ouse notice board. 2.3 Te number of races to count in eac series is sown in te programme. 3.0 Eligibility 22

23 3.1 All series are open to all members wit te following exceptions: Te Ladies Series: Te elm must be female. Te Men Series: Te elm must be male. Te Novice Series: Te elm must not previously ave been placed first, second or tird in any club series. Te Junior Series: Te elm must be under 18 on te 1 st April of te current season. Te Oppi Cup: Oppis only. Te elm must be under 15 on te 1 st April of te current season. Te Topper Series: Toppers only. Te elm must be under 16 on te 1 st April of te current season. Te Brucey Series: Boats must be crewed eiter entirely by Juniors (under 18 on 1 st April of current season) or by one adult and one or more Juniors. Te Single-Handed Series: Te boat must be sailed by one person. Te Double-Handed Series: Te boat must be sailed by two or more people. Te Winter Series: Competitors in tis series will be expected to take an equitable sare in te duties, since tere is no formal rota. 4.0 Race Times 4.1 Te warning signal for te first race of te day will be at 11:00 (unless tere is a Coacing Session instead of racing in te morning). Te warning signal for te first afternoon race will be at 13:30. Te Race Officer will indicate te time of te final afternoon race. 4.2 Groups of races in te Junior/Ladies/Novice Series, Single/Doubled Handed Series and Fewster Cup will be sailed back to back. 5.0 Entering a Race 5.1 Competitors enter a race by signing on on te entry seet beside te race office. 6.0 Liability 6.1 A elmsman is responsible for is/er boat s safety. Weter afloat or asore noting, weter in tis Notice of Race or in te Sailing Instructions or anywere else, reduces tis responsibility. 6.2 Te elmsman must decide weter te boat and te crew are fit for te prevailing or likely conditions. By launcing and setting out to race, te elm confirms tat te boat and crew are fit and competent and ave te relevant experience to sail in tose conditions. 23

24 6.3 Noting done by te organisers can reduce te responsibility of eac elm / crew, nor will it make te organisers responsible for any loss, damage, deat or personal injury, owever it may ave occurred, as a result of te boat taking part in te racing. Te organisers includes everyone elping to run te races and te event and includes te Organising Autority, te Race Committee, te Race Officer, patrol boats and beac masters. 6.4 Te provision of patrol boats does not relieve te elmsman / crew of teir responsibilities. Sailing Instructions 1.0 Rules 1.1 Te racing will be governed by te Racing Rules of Sailing (RRS). 2.0 Notices to Competitors 2.1 Notices to competitors and canges to te Racing Programme will be posted on te notice board in te clubouse. 2.2 Any canges to te sailing instructions will be posted at least 1 our before te Warning Signal. 3.0 Signals Made Asore 3.1 Signals made asore will be displayed on te clubouse flag mast. 3.2 Wen te AP flag is displayed asore, and te race is to be started from a committee boat, te Warning Signal will be made not less tan 20 minutes after te AP flag is removed asore. 4.0 Personal Floatation Device 4.1 Flag Y will not be displayed. Adequate personal floatation must be worn at all times afloat and on te jetty. Wetsuits and dry suits do not constitute personal floatation. Tis canges Rule Class Flags 5.1 Te Class Flag for club racing will be Numeral Pennant Courses 6.1 Courses will be displayed on te club ouse course board or on te committee boat. 7.0 Number of Laps 7.1 Te Round te Lake and Ramblers Series races will be a single lap of te course (unless explicitly varied by te Race Officer). 24

25 7.2 In te Stern Case Series te number of rounds is not pre-determined and boats continue to race until te finising signal. 7.3 In oter series, unless te number of rounds is displayed wit te course, te number of rounds is not predetermined and Average Lap Racing will be used wit an approximate intended race lengt of 20 minutes for Fewster Cup and Junior/Ladies/Novice Series races, 30 minutes for Single/Double Handed Series races and 60 minutes for oter series. 8.0 Marks 8.1 Te positions of te club racing marks are displayed on te plan in te club ouse. 8.2 Te race officer may lay additional marks. 9.0 Te Start 9.1 Starts will be governed by Rule 26 except tat te time sequence will be Tis canges Rule For te Stern Case series te standard starting sequence will be used for te first start but subsequent class starts will be signalled by a sound signal alone. Te start times for eac subsequent class will be calculated using te PY system, and displayed on te notice board prior to te race Start Lines 10.1 Clubouse starts: except for te Stern Case series, te starting line will be between te vertical yellow band next to te club ouse flag mast and te designated start mark. An inner limit mark may be laid Committee boat starts: te starting line will be between te mast of te committee boat and te designated start mark Stern Case starts are off te sore. Boats start from te sore between te club jetty and te stream bounding te foresore on te East side. At eac boat s starting signal, at least one crew member must be olding te boat wile standing on solid bottom. Keelboats may start wit one crew member standing on te club jetty, wit te boat on te East side of te jetty as close to te sore as possible Te Finis 11.1 For Average Lap Races, sortly before te finis, flag S will be displayed wit two sound signals. Tis is te About to Finis (ATF) signal. All boats will finis te race wen tey next pass troug te finis line UNLESS racing an Olympic (trianglesausage) course For Average Lap Races on an Olympic course, if te ATF signal is given before any boat as completed its first triangle lap, all boats will finis te race wen tey next pass troug te finis line, oterwise all boats will finis te race wen tey next pass troug te finis line at te end of a sausage lap. 25

26 11.3 For Stern Case races, at te end of te designated race duration (displayed on te notice boat prior to te race), flag S will be displayed wit 2 sound signals to indicate te end of te race. Te finising order is determined by te position of boats on te course at tat moment. In te event of disagreement te decision of te Race Officer will be final For all oter races flag S as its conventional meaning (sorten course) Finis Lines 12.1 Clubouse finises: te finis line will be between te vertical yellow band next to te club ouse flag mast and te designated finis mark Committee boat finises: te finis line will be between te mast of te committee boat and te designated finis mark Stern Case finises: tere is no set finis line. Finising positions are determined as described in Time Limits 13.1 Tere will be no time limits, but Race Officers may sorten or abandon any race at teir discretion In te event of an abandonment of an Average Lap Race, results may be calculated on te basis of laps already completed. Te decision to do tis will be tat of te Race Officer, wic will be final Declarations 14.1 Competitors must sign off on te results seet on te notice board. Tose failing to sign off witin an our of te last boat finising te last race of te day will be scored as Retired Protests 15.1 Protest forms are available at te race office Protests must be delivered to te race office not later tan 30 minutes after te last boat finises te last race of tat day RYA Racing Carter 16.1 Te RYA Rules Dispute Advisory Hearing is available for club races Te RYA Rules Dispute Mediation Hearing is available for club races Details of te RYA Rules Dispute mecanisms are posted on te club notice board and at ttp:// Handicap System 17.1 Race results for all series except te Stern Case will be calculated using te Portsmout Yardstick (PY) system. 26

27 17.2 Personal andicap results (based on elm s previous results) will be calculated for all series except te Stern Case, and printed on te results seet alongside te straigt PY results Scoring 18.1 All series will be scored in accordance wit Appendix A4 (low points) and A9 (Race scores in a series longer tan a regatta) Te Members doing race officer, patrol and galley duties will score 3 points for te races concerned, but eac elm is only allowed one duty score per series If, in an Average Lap Race, a boat as a iger corrected time tan one of er competitors wit te same or lower PY number, and tat boat as completed a greater number of rounds, ten tat boat s result may be calculated on te same number of rounds as completed by er competitors wit te same or lower PY number, wit te additional round or rounds being discarded. Te decision to do tis will be tat of te Race Officer, wic will be final Discards Te number of races to count in a series is sown in te Sailing Programme. 27

28 Appendix 3 - Qualifications and training records of KWSC members involved. Race Officer o First Aid valid to 15/02/2010 o RYA Dingy Instructor valid to 29/10/2011 o RYA Level 2 Powerboat certificate dated 20/03/2005 Patrol Crew 1Patrol Crew 1 o RYA L2 Powerboat dated 10/02/2008 GP o General practitioner o RYA Safety Boat certificate dated 29/03/2008 DINGHY CREW 3 o First Aid valid to 14/10/2009 o RYA Safety Boat dated 15/10/2006 o RYA Powerboat Instructor valid to 26/11/2011 o RYA Level 2 Race Coac Patrol Crew 2Patrol Crew 2 o Assistant Instructor KWSC dated 28/03/2009 o RYA Level 2 Powerboat certificate dated 24/03/2007 o First Aid - Patrol Crew 2Patrol Crew 2 as an external First Aid certificate via work Member of te club o KWSC Cief Instructor o SI valid to 24/09/2013 o Safety Boat certificate dated 19/10/1997 o First Aid valid to 31/01/2012 Member of te club o First Aid valid to 02/02/2011 o RYA Dingy Instructor valid to 29/10/2011 o RYA L2 Powerboat certificate dated 25/03/2005 Member of te club o RYA Principal from 2009 o RYA Senior Instructor valid to 24/09/2013 o RYA Advanced Instructor o RYA Racing Instructor Endorsement o RYA Level 2 Race Coac o KWSC Commodore 2007/8, 2008/9 o RYA Safety Boat certificate dated 27/02/2000 o RYA Power Boat Instructor valid to 11/02/2013 o First Aid valid to 31/01/

29 Appendix 4 - Details of KWSC Patrol Boat 1 Ribcraft 4.6 m Rigid Hull Inflatable Boat No ull plate visible Mariner 50 ELPT 1998 Serial No Safety Equipment on Board P1 First Aid Kit Trow bags x 2 Toolbox Paddles x 2 Ropes Various Ancor Fuel Can Flares Spare start cord Spare kill cord Bolt croppers Radios Pump for inflatable sponsons Ceck list Kill cord sticker Marks for course setting A frame Towing points Knife Bucket 29

30 Appendix 5 - Laser Stratos RCD Info 30