Learning from incidents
In 2019 there was an inversion incident at an RYA Training and Sailability centre, involving an RS Venture Keelboat. Sadly, this incident resulted in the death of a sailor. During the months that followed, both the club and the RYA assisted with the Marine Accident Investigation Branch (MAIB) investigation, ensuring others are able to learn from the incident.
The full report and safety bulletin is now available from the MAIB:
- Safety bulletin: MAIB SB2/2019
- Full report: Report 20/2020
Over the last 18 months, the investigation and its findings have been the subject of workshops at both the RYA Sailability and RYA Training conferences, as well receiving coverage through MAIB Safety Bulletins and a variety of other mediums of communication. The key to minimising the risk of a repeat of any incident is to ensure that there is an open and constructive discussion about what happened and how it can be avoided in the future.
The MAIB investigation report made several recommendations to the RYA which included a review of RYA Training Inspection processes and some of the supporting documentation. These recommendations have been implemented and have also led to update training for our Inspector team on the conduct of inspections and the expectations we have of inspectors.
We are currently in the process of developing some “self- help” guidance on assessing risk and creating/reviewing safety management systems, as well as a range of other support for RYA Sailability centres.
There are some key messages from this incident for all RYA Training centres, not just those who run the National Sailing Scheme. They include:
- The importance of effective and regular staff and volunteer training
- The need to create regular opportunities to develop, refresh and reflect on skills
- Delivery of safety boat refresher training and/or courses combined with RYA resources such as the RYA Safety Boat Handbook (G16)
- The importance of reviewing and updating Safety Management systems
- Risk assessment and development of operational guidance for new equipment before it is entered into service
- Awareness of changes to RYA Training guidance
- Risk assess, document and familiarise staff, volunteers and users with all centre boats. For example, in the context of keelboating:
- Vessel/equipment behaviour in different conditions
- Lifting keels and knock downs
- Rigging essentials, g. locking mechanisms
- Lifejackets vs buoyancy aids
- AND remember to document and evidence what you do
The RYA has recently revised two Guidance documents which will be useful in addressing some of the points raised above. These include ‘Writing operating procedures’ and ‘Guide to Risk Assessments’.
If you would like further information on keelboats, including some of the key characteristics which should be considered when using them in an RYA Training environment, a recent article in Wavelength provides a little further explanation and understanding, read more here.
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