Knee Fishing Vessel - New Zealand

Transcription

1 Accident Report Capsize, Foundering & Loss of Life Kotuku 13 May 2006

2 Maritime New Zealand Maritime New Zealand (MNZ) is a Crown entity established in August 1993 as the Maritime Safety Authority and renamed with effect from 1 July Safety, security and marine protection are its core objectives. Section 431 of the Maritime Transport Act sets out MNZ s functions. One of those functions is to investigate and review maritime transport accidents and incidents. This accident report is published by: Maritime New Zealand Level 10, Optimation House, 1 Grey Street PO Box , Wellington 6141 New Zealand 2008 This document is available on our website: Maritime New Zealand Investigation Report 2

3 Pond Boards Stern Ramp Photograph 1 (taken pre-accident) Kotuku A Frame Gantry Liferaft Net Roller Freeing Ports Photograph 2 (taken pre-accident) Kotuku Maritime New Zealand Investigation Report 3

4 CONTENTS SECTION PAGE NUMBER Details of Vessel 6 1. Summary Narrative 2.1 An Overview of the Accident Evidence of the Skipper. 2.3 Evidence of one of the Surviving Mutton Birders 2.4 Observations of other Skippers Reliance Aurora Australis Events & Conditions Flowchart 3. Comment & Analysis 3.1 Evidence Vessel Details Vessel Status Vessel History Communication Equipment Bilge Pumping Arrangements Wheelhouse Hatch Covers A Frame Gantry & Pond Boards Freeing Ports Bulwarks Cargo Stowage on the After Deck of Kotuku Crew & Passengers Use of Alcohol/Drugs Hypothermia Vessel Manning Safe Ship Management Safe Ship Management Manual Stability Requirements for Fishing Vessels Inspections & Surveys Rule 40D Review Dry Inclining Test Reduction of Transverse Stability Lifesaving Equipment Lifejackets Liferaft Electronic Positioning Indicating Radio Beacon (EPIRB) Non Release of Kotuku s Liferaft Testing the Release of the Liferaft Geographical & Environmental Conditions in Foveaux Strait Foveaux Strait MetService Data Isoberic Map & Hindcast Maritime New Zealand Investigation Report 4

5 Tidal Flow Conditions in Foveaux Strait Sea Conditions NIWA Data Vessel Search & Rescue Log Details May May May Conclusions Action Taken By Maritime New Zealand Recommendations Comment 73 Photographs & Figures Photograph 1 Kotuku Photograph 2 Kotuku Photograph 3 View of Wheelhouse. Photograph 4 Wheelhouse from Aft Deck... Photograph 5 View of After Deck Photograph 6 Arrangement of Pond Boards. Photograph 7 Freeing Port... Photograph 8 Wood Freeing Port Photograph 9 Liferaft Canister after Removal from Wreck.. Photograph 10 Painter Line.. Photograph 11 Liferaft Canister Contents... Photograph 12 Liferaft and Cradle.. Photograph 13 Underside of RFD Liferaft.. Photograph 14 RFD Liferaft on Purpose Built Cradle... Photograph 15 Weak Link Figure 1 Chart Extract of Kotuku s Track North from the Breaksea Islands. Figure 2 Chart Extract of Muttonbird Islands. Figure 3 Vessel Profile.. Figure 4 Plan of Deck... Figure 5 New Zealand Coastal & Inshore Limits Figure 6 Free Surface Effect Figure 7 Metacentric Height (GM) Figure 8 Probable Capsize Sequence. Figure 9 Correct Installation of Hydrostatic Release Unit. Figure 10 Incorrect Installation of Hydrostatic Release Unit Appendices Appendix 1 MNZ Safety Bulletin Freeing Ports... Appendix 3 SSM Manual Check List... Appendix 4 Schedule 1 Exempted Vessels Appendix 6 Fitness for Purpose Certificate Appendix 7 Fitness for Purpose Certificate Appendix 9 MNZ Inclining Report Appendix 10 Liferaft Report... Appendix 11 Liferaft Neutral Buoyancy Report... Appendix 12 NIWA data... Appendix 14 Weather Data Maritime New Zealand Investigation Report 5

6 DETAILS OF VESSEL Ship Type: Certified Operating Limit: Port of Registry: Flag: Fishing Vessel Coastal Limits of New Zealand trawling limited to within 12 miles of the coast. Bluff New Zealand MSA No.: Built: 1962 Construction Material: Wood Length Overall (m): 14.2 Breadth (m): 3.96 Gross Tonnage: 26 Net Tonnage: Registered Owner: SSM Company: John Edminstin SGS-M&I Maritime New Zealand Investigation Report 6

7 1. SUMMARY 1.1 On 13 May 2006, the fishing vessel Kotuku was en route from the Breaksea Islands, situated off the south east coast of Stewart Island, to Bluff, with nine persons on board (Refer Figure 1). 1.2 Earlier in the day, six of the nine persons, including two children, had been picked up from one of the Breaksea Islands, close to where they had been involved in mutton bird operations. 1.3 The vessel was carrying mutton birds and equipment associated with mutton birding. Four fadges (large bags) with birds and equipment inside them had been loaded on the deck of Kotuku by helicopter, prior to the vessel s departure. 1.4 As Kotuku passed Zero Rock in the Muttonbird (Titi) Islands (Refer Figure 2), the vessel encountered a set of steep waves that caused it to capsize and founder. Of the nine persons on board, four drowned inside the vessel after it capsized. According to pathology reports, another person succumbed to cold water immersion while attempting to swim to shore and another died of hypothermia after reaching the shore. Only three persons survived after swimming to nearby Womens Island (Refer Figure 2). 1.5 Maritime New Zealand (MNZ) commenced an investigation immediately after the accident and dispatched two Maritime Investigators to Bluff. 1.6 Due to the serious nature of this accident, a decision was made, in conjunction with the Transport Accident Investigation Commission (TAIC), to salvage Kotuku to determine the cause of the vessel s capsize and subsequent foundering. 1.7 On 18 May 2006, the Skipper/Owner of Kotuku was interviewed by MNZ. One of the other surviving persons was interviewed by MNZ shortly afterwards. 1.8 MNZ also conducted interviews with eyewitnesses who saw the vessel loading at the Muttonbird Islands and when it was in transit for Bluff. Previous crew and owners of the vessel were also interviewed. 1.9 MNZ gathered physical evidence from the Rescue Coordination Centre of New Zealand (RCCNZ) based in Avalon, New Zealand Police, MetService, SGS-M&I - the vessel s Safe Ship Management (SSM) Company - and RFD, the manufacturers of the vessel s liferaft A series of reports were either commissioned by MNZ or obtained from other sources to provide information on different aspects of the investigation. They are appended to this report The vessel was successfully raised by salvors on 24 May 2006, in position S E, near Zero Rock, at the North Isles (Refer Figure 2). She was beached at Port William, Stewart Island where repairs were carried out to enable it to be towed to Riverton. After arrival at Riverton, the vessel was trucked to Invercargill for further examination and testing In September 2006, MNZ engaged the services of a naval architect to carry out and report on a dry inclining test of Kotuku. This was to determine whether the vessel would have complied with the New Zealand Maritime Rules on stability, if it had undergone an inclining test prior to the accident. The findings of the naval architect are appended to this report All times in this report are New Zealand Standard Time The owner of Kotuku was the Skipper of the vessel at the time of the accident. Throughout this report he is referred to as the Skipper. Maritime New Zealand Investigation Report 7

8 1.15 The purpose of this investigation and report is to determine: The causes and contributing factors that resulted in the vessel s capsize and foundering. To identify learning points arising from this accident with a view to preventing a recurrence. The reason for the failure of the vessel s liferaft to deploy. If there have been breaches of the Maritime Transport Act (1994) and other relevant legislation. If there are any safety lessons that can be learned or dangers that the maritime community should be made aware of Out of consideration to the families of those lost and at the wish of family members, one of the survivors was not interviewed by MNZ until several days after the accident. The youngest survivor was not interviewed at the express wish of his family. This report and its findings should be read with these factors in mind It is recommended that this report be widely promulgated throughout the New Zealand fishing industry and that a copy of the report be forwarded to the secretariats of the International Maritime Organisation (IMO) and pursuant to the Tokyo Memorandum of Understanding The assistance and cooperation provided by the survivors, the Invercargill Police and members of the Bluff and Stewart Island maritime communities is gratefully acknowledged by MNZ. Maritime New Zealand Investigation Report 8

9 2. NARRATIVE 2.1 An Overview of the Accident At approximately 1500 on 12 May 2006, Kotuku departed Bluff for Stewart Island with three persons on board: the Skipper, Mr Hayward, a friend of the Skipper, and Mr Woods, a relief crewmember. On arrival at Stewart Island the vessel anchored in Half Moon Bay At 0745 on 13 May, Kotuku departed Half Moon Bay for Kaihuka Island in the Breaksea Islands Group (Refer Figure 1), where a party of mutton birders had been working and living for several weeks At 1000, after the vessel reached Kaihuka Island, a helicopter from Bluff, carrying the Pilot and Mr Peter Topi, a senior relative of the mutton birders, landed on Kaihuka Island and put Mr Topi ashore. Four fadges containing mutton birds and associated birding equipment were then lifted by the helicopter and landed on the after deck of Kotuku Because of the topography of the Island, it was difficult to transfer the party of mutton birders by dinghy to the vessel. For this reason, they were airlifted by the helicopter to nearby Tia Island (Refer Figure 1), where it was easier to conduct a transfer When Kotuku reached Tia Island, the mutton birders and Mr Topi senior were transferred to the vessel by dinghy for the trip back to Bluff At approximately 1115, Kotuku departed Tia Island and headed north, en route to Bluff in relatively calm seas. Freshening north westerly winds were forecast for later in the day Due to the favourable weather conditions, a decision was made to proceed directly for Bluff. An alternate plan, in the event of encountering rough seas, had been to stop at Half Moon Bay on Stewart Island, so that some of the mutton birders could disembark. They would then have travelled across Foveaux Strait and to Bluff by a commercial ferry As Kotuku proceeded north towards the Muttonbird Islands via Carter Passage (Refer Figure 1), the vessel s course took it to the east of Herekopare (Te Marama) and Edwards (Motunui) Islands (Refer Figure 2) At approximately 1430, Kotuku passed the North Isles (Refer Figure 2) to starboard. After passing Zero Rock, situated off the northerly tip of North Island, the Helmsman, Mr Topi senior, altered course to starboard in the direction of Bluff. A light to moderate west to north-west wind was blowing at approximately 10 to 12 knots with corresponding seas of just over one metre (m) in height Up to this point the trip had been uneventful. The vessel was riding easily in the prevailing sea conditions and the vessel s navigational aids, main engine and ancillary equipment, were functioning properly After the alteration to starboard and after steadying on a broadly north-north-east heading, the Helmsman and some of those in the wheelhouse observed a set of waves, approaching from a direction that was approximately 30º on the port bow. The survivors stated that when first sighted the waves appeared to be not more than 2m in height and did not give any cause for concern or indicate that they might threaten the safety of the vessel. The waves were not cresting and initially were not thought to be unduly steep. Maritime New Zealand Investigation Report 9

10 The Helmsman however altered course to starboard to take the waves on the stern, but before the vessel could complete the turn to starboard the first wave struck Kotuku on its port beam. This caused the vessel to lurch violently and roll heavily to starboard. The vessel then righted itself and rolled back to port, when another wave was shipped on board. The vessel then commenced a final slower roll to starboard. At that point, the after deck, to the level of the top of its bulwark rails, was observed to be awash with water. A number of empty fish boxes that had been stowed against the bulwark rail on the starboard side of the vessel, adjacent to and abaft the wheelhouse, started floating off the deck from the seas that had been shipped on board The Helmsman, assisted by one of the survivors, then applied port helm in an unsuccessful attempt to bring the head of the vessel into the seas. In the meantime, the vessel continued its slow roll to starboard. After the starboard deck edge was immersed and the starboard side of the wheelhouse reached sea level, downflooding into the wheelhouse occurred through an open window on the starboard side. At this point, Kotuku capsized, turning through an arc of 180º, with the hull fully inverted Of the nine persons on board, only five were able to escape the flooded wheelhouse and reach the surface. Three of them were able to climb onto the vessel s upturned hull. The other two, the Skipper and Mr Hayward, clung to one of the fadge s which had floated off the vessel when it capsized. They then started swimming towards North Island (Refer Figure 2) The tidal stream carried them past the eastern side of North Island. The Skipper was eventually able to swim to Womens (Pico) Island that lay just to the south. Before reaching the safety of the shore Mr Hayward succumbed to drowning due to hypothermia The three persons on the upturned hull remained there for some hours as it drifted down the eastern side of North Island and Womens Island. They eventually decided to abandon the upturned hull at a point where they considered they had the greatest chance of successfully swimming to Womens Island All three reached Womens Island but Mr Woods became separated from the others during the swim to shore. He succumbed to hypothermia on Womens Island The two survivors on Womens Island were able to find shelter and clothing in a hut. As darkness fell, they started signalling to a nearby vessel, using equipment found in the hut. These signals were acknowledged At approximately 1750, when Kotuku failed to arrive in Bluff, the Half Moon Bay radio operator at station ZLRZ, sent out a call on Very High Frequency Radio (VHF) channel 65, enquiring as to sightings of Kotuku. A number of search vessels immediately departed Bluff and Half Moon Bay for the North Isles At approximately 1954, one of the search vessels was able to approach the shoreline on Womens Island, within hailing distance of two of the survivors, who were then able to tell what had happened An intensive search of the nearby islands, and the surrounding sea area, was started under the direction of RCCNZ. This involved a large number of vessels and aircraft. Search vessels subsequently located debris and found an oil slick with bubbles floating to the surface, north-west of Zero Rock, that subsequently proved to be the position of the wreck of Kotuku At approximately 2030, the Skipper was rescued from the western shoreline of Womens Island Mr Hayward s body was later found on the surface south of Womens Island At about 2130, the other two survivors were airlifted by helicopter from Womens Island and taken to Stewart Island. Maritime New Zealand Investigation Report 10

11 On the morning on 14 May Mr Wood s body was found on Womens Island. Later in the day the body of one of the mutton birders was found on the surface near the wreck On 15 May, Police dived on the wreck and located the bodies of the missing adult and the two children inside the hull. Kotuku was found heeled over on its starboard side, on a seabed of broken shell and sand, in about 30m of water At 1155 on 15 May, rescue operations were terminated. (Excerpts of NZ Chart 69 on Figure 1, showing the track of Kotuku towards Bluff and NZ Chart 6823 on Figure 2, showing the Muttonbird Islands, the point of capsize and the estimated drift of Kotuku after it capsized). Figure 1 Kotuku s track north from the Breaksea Islands Chart courtesy of Land Information New Zealand. Maritime New Zealand Investigation Report 11

12 Wreck Drift North Position Of Capsize Position Hull Last Seen Drift South Position Where Skipper Reached Shore Position Where Two Survivors Reached Shore Kotuku s Track North Figure 2 Muttonbird Islands approximate position of capsize and landing positions Chart courtesy of Land Information New Zealand 2.2 Evidence of the Skipper The Skipper remembered Kotuku rolling to starboard to an angle of approximately 15 to 20 as it was hit by a wave, which was larger than those the vessel had previously encountered that day. Afterwards, the vessel rolled back to port and then to starboard, to an angle of approximately 25 to 30, until water started to come through an open starboard wheelhouse window. He believed Kotuku was struck by three waves, the first of which caused the vessel to roll heavily to starboard. The second wave struck after the vessel rolled heavily back to port and this caused the vessel to roll back to starboard. The Skipper believed the action of the third wave striking the vessel caused it to capsize. Maritime New Zealand Investigation Report 12

13 2.2.2 The Skipper was sitting down immediately prior to the vessel capsizing and as such was unable to accurately judge the vessel s angles of roll. He recalled the Helmsman, Mr Topi senior, altering course to starboard in an attempt put the vessel s stern to the waves. He could not recall if the head of the vessel started to turn to starboard immediately prior to, or after, it was hit by the set of waves. When the vessel capsized, he and Mr Topi senior were thrown across the wheelhouse. The Skipper believes he may have escaped through the open starboard wheelhouse window and was able to reach the surface with four other persons. Three of them were able to climb onto the upturned hull The Skipper, and Mr Hayward, who could not swim, clung to one of the fadges which had drifted clear of the vessel. The Skipper tied Mr Hayward to the fadge. As they drifted away from Kotuku, the Skipper noticed the tide was setting them southwards, past the northern extremity of North Island. When they were approximately 100 to 130m to the east of Womens Island, Mr Hayward lost consciousness and died. The Skipper then abandoned the fadge and swam to the shore. After reaching the shore, and as darkness fell he could see the lights of a number of search vessels. He was subsequently rescued by helicopter and taken to Stewart Island The Skipper recalls the echo sounder recording a depth of 14 fathoms (25.8m) shortly before the vessel capsized The last visual check of the engine room made by the Skipper was on departure from Kaihuka Island. At that time the Skipper, as part of his normal routine before departure, switched on the pump for the engine room bilge for a short period of time He could not recall if the wheelhouse door, leading to the after deck, was open or closed at the time of capsize During his ownership of Kotuku, he had never observed seas of this magnitude breaking over the vessel s bulwark rails He states that he did not receive any financial benefit from the trip. He thought he might be offered some mutton birds and a contribution for the cost of fuel but there was no express agreement to that effect He was not aware Mr Topi senior intended travelling to Bluff on Kotuku until he was transferred on board. 2.3 Evidence of one of the Surviving Mutton Birders The Survivor stated that the trip north from Tia Island towards the Muttonbird Islands, was uneventful. On passing North Island, Mr Topi senior, the Helmsman, altered course for Bluff The survivor then saw a set of two waves, which he described as rollers of no more than 2m in height, approaching the port bow. His immediate reaction was that they posed no threat to the vessel. He recalled Mr Topi senior turning the wheel about half a turn to starboard. A total of two and a quarter turns of the wheel was required to turn the rudder hard to port or starboard from the midships position When the first wave struck, the vessel rolled to starboard, recovered to the upright position and then rolled to port. As the vessel started to roll back to starboard, Mr Woods, who was near the after wheelhouse door, shouted that something was wrong and that fish boxes, which had been stowed on the after deck against the starboard bulwark rail, were floating off the deck. Mr Topi senior then turned the wheel hard to port. The Survivor also grabbed the wheel to assist but the vessel continued its slow roll to starboard and capsized. The Survivor s initial thought was to get his son and nephew out of the forecastle accommodation but there was no time to do so. Maritime New Zealand Investigation Report 13

14 2.3.5 The Survivor was able to swim through the open starboard wheelhouse window and, on reaching the surface, to climb on to the upturned hull with his other nephew and Mr Woods. They remained there for some hours until they started drifting to the south-east, away from Womens Island When he first climbed onto the hull, the Survivor could hear the vessel s main engine still running but noticed the propeller was not turning. He saw no sign of any hull damage or any venting through the hull as the vessel started to go down by the head. He observed the Skipper and Mr Hayward, who were holding onto one of the fadges, attempting to reach shore The crew on the hull remained there for some time as it continued to drift to the southeast. When it became apparent it was not drifting any closer to shore, a decision was made to swim for Womens Island before darkness fell. After leaving the upturned hull, the Survivor and his nephew became separated from Mr Woods and they did not see him again. On reaching the Island, the vessel s hull was still visible. Both men found clothing from a mutton birder s hut and started a fire Just as darkness was falling, the Survivor attempted to sight the Skipper and the hull but could not see anything. He saw the lights of a nearby vessel and started flashing SOS signals with flashlights and waving a burning cloth on a pole made from materials found in the hut. These signals were acknowledged. A second vessel then came within hailing distance and they were able to explain what had happened After some hours, a rescue helicopter landed and took both men to Stewart Island The Survivor stated that prior to capsize, Kotuku was handling well. He could not recall if any of the freeing ports, on the port and starboard side of the vessel, were open or closed. About thirty minutes prior to capsize the Survivor activated the electric bilge pump from the wheelhouse as part of his normal routine for pumping the engine room bilge The Survivor stated that when the seas broke over the top of the port bulwark rail, they loaded the deck with so much water that it was sufficient to cause the vessel to capsize. He estimated that approximately one-third of the vessel s length abaft the wheelhouse must have been under water for the empty fish boxes to float off. He considered the angle of heel would not have been enough, in normal circumstances, to allow downflooding through the window. He attributed downflooding to the reduced freeboard caused by the weight of water on deck. 2.4 Observations of Other Skippers Reliance The Skipper of this fishing vessel was one of the last observers to see Kotuku before the accident. Reliance was also loading at Kaihuka Island and departed, with mutton birders and cargo, just after Kotuku. Reliance is of a similar length to Kotuku with a slightly wider beam On the day of the accident, the Skipper departed Bluff for the Breaksea Islands and arrived at Kaihuka at Kotuku arrived approximately ten minutes later. The loading of mutton birds by helicopter onto Reliance commenced at 1000 and was completed by The Skipper took video footage of Kotuku being loaded and watched the vessel depart for Tia Island. The footage showed Kotuku trimmed slightly by the stern. He overtook Kotuku when it stopped at Tia Island to embark the mutton birders. Maritime New Zealand Investigation Report 14

15 The Skipper s course took him to the east of Bench Island whereas Kotuku s course took it to the west (Refer Figure 1). His last sighting of Kotuku was just south of Carter Passage when it was about 1½ to 2 miles distant. From his observations the vessel appeared to be riding well in the seaway When Reliance passed to the east of the Fancy Group of Islands (Refer Figure 1), the Skipper estimated the north westerly wind force to be 20 to 25 knots with a corresponding moderate sea At approximately 1300, as he passed through the Fancy Group and was abeam of the Bunker Islands, the Skipper recalled encountering a set of waves, bearing about 40 to 50 on his port bow, that were approximately 2m in height. He described them as being larger than those previously encountered but not excessively so. The vessel rode the two waves with little difficulty. Unlike Kotuku, which had retractable paravanes, Reliance had a fixed stabilizer arm, which was permanently deployed At 1530, the Skipper arrived at Bluff Harbour after an uneventful crossing of Foveaux Strait At approximately 1730, he contacted the Halfmoon Bay radio operator (ZLRZ) after hearing that there was concern as to the whereabouts of Kotuku. He immediately joined other search vessels from Bluff en route to the North Isles. Later that evening his vessel recovered the body of Mr Hayward south of Womens Island The Skipper stated that based on his experience of operating in the area of the Muttonbird Islands, it is not uncommon to encounter sets of waves that are larger than those which normally prevail. In his opinion, the sea conditions which he encountered should not have been a threat to a vessel the size of Kotuku Aurora Australis The Skipper of this vessel is an experienced operator with 36 years experience in Stewart Island waters. When sea conditions permit, he passes through the area where the accident occurred on a daily basis. On the day of the accident, his vessel was transporting a hunting party from Bluff to Port Adventure, Stewart Island. He passed close to North Island at 1100, about 3½ hours before Kotuku. At that time, the wind speed was between 15 to 20 knots from the north west, with seas of less than 1m in height At approximately 1145, as Aurora Australis travelled southwards towards Port Adventure, the Skipper saw Kotuku travelling north off Chew Tobacco Bay (Refer Figure 1). The distance was too far to make any observations as to how she was riding. He believed she was hugging the coast to avoid the adverse flood tide In reply to questions relating to local sea conditions, the Skipper stated he had been subjected to a counter current close to shore around Womens Island and North Island. In these conditions steeper than normal seas were experienced with a distinct line of rough water visible. He said that sea conditions often improved 100 to 200m further out in Foveaux Strait At 1650, after returning to Half Moon Bay, he was telephoned by the Half Moon Bay shore station ZLRZ in relation to Kotuku being overdue at Bluff. At 1800, he reached the search area and found floating debris in the area of Womens Island. Maritime New Zealand Investigation Report 15

16 2.5 Events & Conditions Flowchart Key: EVENT CONDITION ACCIDENT At approximately 1500 on 12 May 2006, Kotuku departs Bluff for Half Moon Bay, Stewart Island. There are 3 people on board consisting of the Skipper, a friend of the Skipper and a relief crew member. Kotuku is carrying about 1700 litres of diesel oil and 150 litres of other oils. About 1 tonne of ice is stowed in the fish hold. A total of empty fish boxes are stowed on the starboard side of the after deck. Kotuku arrives at Half Moon Bay and anchors overnight. At 0745 on 13 May, Kotuku departs Half Moon Bay for Kaihuka Island in the Breaksea group of Islands. A party of mutton birders who have been working on the Island are waiting to be picked up by Kotuku for the return passage to Bluff. At 1000, Kotuku arrives at Kaihuka Island. A helicopter lands on Kaihuka Island from Bluff with a senior relative of the mutton birders. Four fadges containing mutton birds and the mutton birder s equipment are lifted by the helicopter and landed on the after deck of Kotuku. Their combined weight is about 1500 kgs. Three of the fadges are stowed between pond boards and one against the port bulwark rail. All the freeing ports, save for one on the after starboard side, are blanked with sliding covers. The mutton birders are transferred by helicopter to Tia Island where it is easier to conduct their transfer by dinghy to Kotuku. Before Kotuku leaves for Tia Island, the Skipper runs the electric engine room bilge pump for a short while as part of his normal practice. Maritime New Zealand Investigation Report 16

17 At approximately 1115, after 5 mutton birders and their senior relative have been transferred by dinghy, Kotuku departs Tia Island for Bluff. The forecast for Foveaux Strait, issued on 13 May, is for westerly winds of 15 knots, rising to northwest winds at 25 knots in the morning and to 35 knots in the evening. Sea is forecast to become very rough and the south west 3m swell to ease. Kotuku s track to the north is close to the east coast of Stewart Island to minimise the effect of the adverse flood tide. The vessel is riding easily in the prevailing sea conditions. All on board equipment, including navigational aids, main engine and ancillary equipment are functioning properly. Alcohol, in the form of beer and wine, is consumed by the Skipper and some of the persons on board. This does not include the senior relative of the mutton birders, who is steering the vessel manually. About 30 minutes prior to the vessel capsizing, one of the mutton birders, who is an ex-skipper of the vessel, activates the electric bilge pump as part of his normal routine, using a remote switch in the wheelhouse. At approximately 1430, Kotuku passes Zero Rock, situated off the northerly tip of North Island in the Muttonbird group of Islands. The helmsman alters course to starboard onto a north north easterly heading in the direction of Bluff. A light to moderate west to northwest wind is blowing at approximately knots with seas of just over 1m in height. A set of two waves, initially estimated to be about 2m in height, are observed approaching from a direction approximately 30 on the port bow of Kotuku. The helmsman alters course to starboard to take the waves on the stern. None of the survivors who were interviewed thought the waves were unduly steep or likely to endanger the vessel. Maritime New Zealand Investigation Report 17

18 The first wave strikes Kotuku on her port beam, causing the vessel to roll heavily to starboard. The vessel rolls back to port and ships another wave before rolling back to starboard and then capsizing. After the second wave strikes the vessel, the relief crew member shouts out that something is wrong and that the fish boxes on the starboard side of the after deck are floating off the vessel. The helmsman, assisted by one of the survivors, puts the wheel hard to port in an attempt to rectify the situation. Despite this action, the vessel continues to roll slowly back to starboard. The after deck is awash with water. The starboard deck edge is then immersed followed by water entering the wheelhouse through an open window on the starboard side. Kotuku turns through an arc of 180 with her hull fully inverted. Of the nine persons on board, five are able to escape the flooded wheelhouse and accommodation and reach the surface. Three of them climb onto the upturned hull whilst the Skipper and his friend cling to one of the fadges that have floated off the vessel when it capsized. One of the survivors on the upturned hull hears the main engine still running but notices the propeller is not turning. He cannot see any sign of hull damage or venting through the hull as the vessel starts to trim by the head. The upturned hull of Kotuku starts to drift south east past North Island & Womens Island. The Skipper and his friend continue to drift clear of Kotuku as they cling to the fadge. When they are about m to the east of Womens Island, the Skipper s friend loses consciousness and dies.. His body is later recovered from the sea by a rescue vessel. In the meantime, the Skipper manages to swim to Womens Island. The three men on the hull decide to swim to Womens Island as the vessel is not drifting any closer to shore. During the swim the relief crew member becomes separated from the others. His body is later found on the island. Maritime New Zealand Investigation Report 18

19 At about 1750, when Kotuku fails to arrive in Bluff, the local radio station sends a call on VHF 65 enquiring of any sightings of Kotuku. A number of search vessels depart Bluff and Half Moon Bay for the Muttonbird Islands. Two of the survivors on Womens Island, find shelter and clothing in a mutton birders hut. As darkness falls, they see a nearby vessel and start signalling using equipment they have found in the hut. These signals are acknowledged. The Skipper, who observes the lights of a number of search vessels, is later picked up by a helicopter after he is found on the shoreline. An intensive search of the nearby islands and surrounding sea area is conducted for signs of the upturned vessel. Search vessels subsequently locate debris and find an oil slick with bubbles floating to the surface at a point north-west of Zero Rock, which later proves to be above the sunken position of Kotuku. At about 2125, two of the survivors are airlifted by helicopter from Womens Island and taken to Stewart Island. At approximately 2128, the body of the friend of the Skipper is recovered from the sea, south of Womens Island. On 14 May the body of the relief crew member is found on shore and the body of one of the mutton birders is found near the wreck. On 15 May, Police dive on the wreck of Kotuku and recover the bodies of the missing adult and the two children inside the hull. Kotuku is found heeled over on her starboard side, on a sea bed of broken shell and sand, in about 30m of water. The vessel s liferaft is still stowed inside its cradle. At 1155 on 15 May, rescue operations are terminated. Maritime New Zealand Investigation Report 19

20 3. COMMENT & ANALYSIS 3.1 Evidence Vessel Details At the time of the accident Kotuku held a valid Safe Ship Management (SSM) Certificate enabling it to operate within Coastal Limits with trawling limited to within 12 miles of the New Zealand coast (Refer Figure 5) Kotuku was owned and operated by a local Bluff fisherman The SSM Certificate issued by the vessel s SSM Company, SGS-M&I, was due to expire on 15 November 2009, subject to periodical audit/inspection of the vessel and its safety management system The vessel had an overall length of 14.2m, a gross tonnage of 26 and a beam of 4.3m On the day of the accident, the Skipper estimated the after freeboard of the vessel, between the vessel s main deck and the sea surface, to be approximately ½m. The Skipper stated the overall height between the top of the vessel s bulwark rails, at the after end of the vessel, and the sea surface was approximately 1m Propulsive power was provided by a Caterpillar diesel engine, model D333A, developing kw via a twin disc gearbox on a 4.45: 1 reduction. The vessel was fitted with a three inch propeller shaft attached to a 44 X 32 inch pitch fixed propeller, which gave a service speed of about 8 knots Kotuku was fitted with a vertically continuous watertight collision bulkhead that extended to the height of the main deck, as required by Maritime Rule Part 40D.11(1) Watertight Bulkheads. Four non-watertight bulkheads separated the forepeak, forecastle accommodation area, engine room, fish hold and the after lazerette hatch (Refer Figure 3). As Kotuku was under 16m in length it was not required to be fitted with watertight bulkheads extending to the first deck above the vessel s design waterline, at each end of the machinery space, under Maritime Rule Part 40D.11(4) The Skipper stated the vessel was carrying 1700 litres of marine diesel oil when it left Bluff on its last trip. This was close to the vessel s full diesel oil capacity of about 1850 litres. The two main fuel tanks, positioned at the after end of the vessel, were each capable of carrying approximately 650 litres of marine diesel oil. A third fuel tank, situated on the forward starboard side of the engine room, carried approximately 550 litres of marine diesel oil Positioned immediately forward of the above tank was a 60 litre hydraulic oil tank that was used for the vessel s steering system One 20 litre drum of hydraulic and lube oil was stowed in the engine room. Three additional 20 litre drums of oil were stowed in the aft hold A half full 20 litre drum of engine oil was lashed to the after bulkhead in the engine room Two fresh water tanks were positioned on the port side of the engine room. They were estimated to have contained a total of 198 litres of water Two additional barrel tanks also containing fresh water, were situated on top of the wheelhouse. They were estimated to have contained a total of 138 litres of water Two 20 litre containers of water were stowed in the aft hold. Maritime New Zealand Investigation Report 20

21 3.2.1 Vessel Status On 13 May 2006, when the accident occurred, Kotuku was not involved in commercial trawling activities but transferring mutton birders and their equipment to Bluff. The Skipper considered the vessel was not plying for hire and reward and therefore was not operating commercially. Under the definition set out in section 2 of the Maritime Transport Act 1994 (MTA) the vessel was not a pleasure craft. Consequently it was required to comply with the Maritime Rules Section 2 of the MTA states as follows: Pleasure craft means a ship that is used exclusively for the owner's pleasure or as the owner's residence, and is not offered or used for hire or reward; but does not include (a) A ship that is provided for transport or sport or recreation by or on behalf of any institution, hotel, motel, place of entertainment, or other establishment or business; (b) A ship that is used on any voyage for pleasure if it is normally used or intended to be normally used as a fishing ship or for the carriage of passengers or cargo for hire or reward; (MNZ Emphasis) (c) A ship that is operated or provided by any club, incorporated society, trust, or business On the basis of the above, MNZ considers the vessel would have been operating as a commercial fishing vessel at the time of the accident and accordingly would still be subject to the requirements of Maritime Rule Part 40D - Design, Construction & Equipment Fishing Ships Vessel History Despite extensive enquiries, MNZ was unable to obtain any lines plans of the vessel. These typically consist of three perpendicular views of the hull to include the profile or sheer plan of one side of the vessel; the half-breadth plan which is the view of the vessel from directly above and the body plan which consists of views of the vessel from directly ahead and astern. Archive material of the vessel contained only a basic plan of the vessel. The vessel details shown on Figures 3 & 4 are based on this plan, on information provided by survivors and from measurements taken from the damaged hull after the accident Kotuku was built in 1963 by Curnow and Wilton in Nelson. The hull and deck of the vessel were constructed of white pine (kahikatea) over rimu beams Initially Kotuku operated predominately in the Nelson area, the Chatham Islands and the west coast of the South Island. The vessel s home port for a considerable period of time was Greymouth The present Skipper purchased the vessel in After a year working in the tuna fleet off the west coast of the South Island, the vessel started operating out of Bluff in 1996 and continued to do so, without incident, until the accident The vessel s deck layout was altered considerably in 1988 when the fish hold was enlarged. Additionally, new fuel tanks were installed in the engine room and a higher A frame gantry was fitted above the main deck (Refer Photographs 1, 2 & 6). These alterations were inspected and approved by the then Marine Department of the Ministry of Transport. Maritime New Zealand Investigation Report 21

22 Previously, the trawl net had been stowed at the after end of the main deck, under a set of gallows, which extended a much lower distance above the main deck than the subsequent A frame gantry. A previous crewmember stated that prior to making the above alterations, the vessel had a raised fish hold that ran aft along the main deck from a point abaft the wheelhouse. Access to this compartment was via a door situated at the after end of the hold After the higher A frame gantry was fitted, a previous crewmember observed that when the vessel was operating in rough seas, it did not recover as quickly from a roll as it had done before. He also found that the vessel was trimmed lower by the stern. Previously, the vessel was fitted with a single mast and a lifting boom that was used to recover the net when the vessel was engaged in trawling operations The previous crewmember considered the vessel to be a good sea boat prior to the alterations being made. He stated that both he and other crew members had concerns about the vessel s stability after the alterations were made, as the vessel was slower to return to the upright when it rolled in moderate to rough seas A previous Skipper stated the vessel had carried 11.5 tonnes of tuna without incident when it was fitted with the raised fish hold and the lower gallows A boat broker, who was a previous Skipper of the vessel in the early 1970s, examined Kotuku approximately 18 months prior to the accident. At that time, he was not prepared to list the vessel for sale on the grounds that he considered it to be in poor condition. He specifically mentioned finding a number of soft wooden transverse deckhead beams in the vicinity of the stairway to the engine room. He was disappointed at its run down condition, saying the vessel was very untidy. He expressed his concern to the MNZ Maritime Investigator, after this accident, that the vessel had been given a valid SSM Certificate. The vessel s SSM surveyor, when interviewed after the accident, considered that whilst the vessel may have been of untidy appearance, she was seaworthy. He said that only the exterior surface of the deckhead beams were superficially soft and that the inner core was unaffected and strong Kotuku was not operating over the period when examined by the broker due to illness of the Skipper Communication Equipment The vessel was equipped with a Uniden MC 760 VHF radio that was located in the wheelhouse. The last radio survey was carried out on 8 November This included a test of the Electronic Position Indicating Radio Beacon (EPIRB) which was stowed in the wheelhouse, forward of the helm position (Refer Photograph 3) There were three mobile telephones on board but none of these could be used after the vessel capsized as they were not kept in sealed waterproof bags. MNZ has promoted the importance of this type of telephone being packed in waterproof bags as a means of communication in an emergency There have been a number of fatal accidents in recent years, both recreational and commercial, where people, who had no means of being able to communicate their predicament, have lost their lives The use of waterproof handheld VHF radios enable calls to be heard by other vessels in the area and by the New Zealand Maritime Operations Centre in Avalon. This keeps a 24 hour listening watch of all VHF Channel 16 traffic and other distress frequencies. Maritime New Zealand Investigation Report 22

23 MNZ has investigated a number of accidents where, if an EPIRB had been activated, lives would almost certainly have been saved. A 406 MHz EPIRB on a hydrostatic release, placed externally on a vessel, at a point clear of any obstruction, would usually enable the unit to float to the surface in the event of a sudden capsize and commence transmitting an emergency signal. Unfortunately, the sudden capsize of Kotuku and flooding of the wheelhouse, prevented anyone from grabbing the EPIRB that was stowed in the wheelhouse Whilst, for reasons expressed later in the report, the vessel s liferaft did not float free after the accident, evidence obtained during other MNZ investigations has shown the benefit of equipping liferafts with 406 MHz EPIRBs so that communication can be established after abandoning ship Bilge Pumping Arrangements Kotuku had a 12 volt electric bilge pump located in the engine room bilge that was activated automatically by a float switch. This was located at the after end of the engine room and screwed on to the keel. The electric one inch bilge pump could also be activated remotely, using switches that were located on the starboard side of the wheelhouse, just above the hatchway opening to the engine room. An additional two inch engine room bilge pump was operated off the power take off at the forward end of the main engine. This was activated by entering the engine room and opening and closing two valves Neither the Skipper nor the vessel s SSM Surveyor could recall the lift capacity of the two bilge pumps fitted to Kotuku Rule Part 40D.28(1) - Bilge Pumping Arrangements states: an efficient bilge pumping system must be provided that under all practical conditions must be capable of pumping from and draining any watertight compartment that is not a permanent oil or water tank whether the ship is upright or listed Rule Part 40D.28(6)(h) states: on ships of 12m or more in length emergency bilge pumping arrangements must be provided for compartments outside the main machinery space which are fitted with only one submersible bilge pump. This may be a portable submersible self -priming pump of 8m³/hour capacity, which is stowed with its hoses in a readily accessible location The vessel s engine room, fish room and lazerette had a common bilge. Limber holes had been cut in way of the divisional bulkheads separating these compartments. This was to allow water to drain from each compartment to the bilge in the engine room from where the water could be pumped over the side Rule Part 40D.28(8) states: any ship which has the propulsion machinery fitted in an enclosed watertight compartment that contains through hull fittings and that is periodically unattended, must be fitted with a bilge level device that is connected to an audible alarm located near the steering position. The power supply for the audible alarm must be available at all times when there is any person on board By virtue of having limber holes connecting the engine room with other sections of the vessel, Kotuku was not required to have an audible bilge alarm system. Maritime New Zealand Investigation Report 23

24 It is doubted whether the lack of an audible bilge alarm contributed to the vessel s capsize. Firstly, there is no evidence to indicate any sudden loss of integrity in the vessel s hull prior to the vessel s capsize caused by water within the hull. Secondly, one of the survivors activated the electric bilge pump, as part of his normal routine, about thirty minutes before the accident occurred, at a time when the vessel was riding easily Wheelhouse The wheelhouse was of a standard configuration for a fishing vessel of Kotuku s age. One means of entry to the wheelhouse was gained from a doorway located on the after port side. It is not known whether this door was open or closed at the time of the vessel s capsize (Refer Photograph 4). The other means of entry into the wheelhouse was located on the forward port side, immediately adjacent to the helm position. It consisted of a sliding door, raised above deck level, which was closed at the time of the accident (Refer Photograph 3) The entrance to the engine room was via a hinged wooden hatch situated on the forward starboard side of the wheelhouse deck. A short open stairwell, that was on the vessel s centre line at the forward end of the wheelhouse, led down to the accommodation area where the two children were situated when the vessel capsized (Refer Photograph 3) Only one of the wheelhouse windows, situated on the starboard side, was open immediately prior to the vessel capsizing When the vessel was raised after the accident, divers found that the forward gear of the main engine was engaged with the throttle set at slow ahead. It is possible that the throttle and gear controls may accidentally have been knocked by those in the wheelhouse as the vessel capsized Split trawl winches and the anchor winch were located on the fore deck forward of the wheelhouse. The mast was stepped on deck at a point immediately forward of the wheelhouse (Refer Photograph 2). Maritime New Zealand Investigation Report 24