Speeches

Concordia Investigation Press Conference Speaking Notes


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Check Against Delivery

Julie

Slide 1: Introduction

Good morning ladies and gentlemen,

My name is Julie Leroux and I am the media relations specialist for the Transportation Safety Board of Canada.

We are here in Halifax today to release our investigation report into the knockdown and capsizing of the sail training yacht Concordia off the coast of Rio de Janeiro, Brazil on 17 February 2010.

Our presentation will take approximately 20 minutes, followed by a question and answer period.

Following that the panelists will take a ten-minute break and then make themselves available for any one-on-one interviews. Should you want an interview with a member of the panel, please contact me and I will schedule you on a first come, first served basis.

The news conference is being simultaneously translated. English is on channel one of your headset and French is on channel two.

Slide 2: Panelists

Our presenters today are Mr. Jonathan Seymour, Member of the Board, Mr. Paulo Ekkebus, the Investigator-in-Charge of this investigation, and Ms. Abigail Fyfe, Naval Architect and Senior Investigator. Mr. Pierre Murray, Manager of Marine Investigations, Atlantic Region, will be our French spokesperson.

I ask you now to turn off your cell phones and other devices or put them on vibrate.

Member Seymour.

Jonathan

Thank you for joining us today. 

Slide 3: Sail Training Yacht Concordia

On 17 February 2010, the sail training yacht Concordia, was knocked down and capsized after encountering a squall off the coast of Brazil.  All 64 crew, faculty and students abandoned the vessel into liferafts.  They were rescued two days later by merchant vessels and taken to Rio de Janeiro.

Because of the vessel's close ties to Canada, and the fact that many of the witnesses are located here, the TSB launched an investigation into the accident.  Our job, as Canada's independent transportation accident investigation agency, is to establish what happened and why.  And to provide decision makers with the information they need to ensure something similar does not happen again.

Many of you will have heard that Concordia was overcome by a vicious microburst associated with a tropical storm.  But the TSB found no evidence that there was such a microburst. On the contrary, satellite imagery, expert assessment and on board observations suggest that the wind speeds were not extreme.  Certainly the conditions were no worse than those this vessel must have encountered many times before during its 20-year history.

A lot was done well on the Concordia and helped those on board to survive.  It was equipped with many more liferafts than required by regulation; the lifejackets were accessible in deck lockers; and the ships complement had been regularly drilled in emergency procedures.

So what happened? No one factor caused this accident.  Rather it was a combination of the inherent limits of the Concordia; a lack of knowledge of these limits on the part of the officer of the watch; the associated lack of awareness of the developing risks; and, consequently, the absence of mitigating action to reduce sail, change course or batten down the hatches.

This presentation will provide you with an explanation of what happened to Concordia. And it will end with our two recommendations. 

These are designed to ensure that every sail training vessel has the necessary information on board that defines their individual vulnerability to specific weather conditions, and that all deck officers are trained in the use of this information. 

I now turn to Paulo Ekkebus, the Investigator in Charge, who will walk you through the history of the voyage, the knockdown and capsizing, the abandonment, search and rescue, and an analysis of the prevailing weather.

Paulo

Thank you, Member Seymour.

Slide 4: Occurrence Voyage

On February 16 2010, the Concordia was transiting the southern portion of the Atlantic Ocean, off the coast of Brazil. According to the weather forecasts, the vessel was to travel through a cold front, with conditions expected to worsen.

Slide 5: Sail Plan

On the morning watch of February 17th, the master, in anticipation of this rougher weather, changed the sail plan.

Slide 6: Handover of the Watch

At noon, he handed over the watch to the second officer, with advice that the sail plan was good to 40 knots, and instructions to bear off and run before any encountered squalls. The master also had standing orders that he was to be called if weather conditions were judged to pose a risk to the vessel. Then, the master went below to rest.

At 2 in the afternoon, this is how things stood: classes were underway in both the mess and the aft classroom, and the day watch had changed. The officer of the watch had 2 lookouts on the bridge wings and several students available on deck. In all, there were 36 people on the main deck with the remaining 28 people below decks.

Slide 7: Animation

The animation you are about to see is a representation of the events that followed. Depictions of the meteorological and sea conditions and the vessel's behavior are approximations based on the compilation of all the information gathered during the TSB investigation. As the animation starts, there was an overcast sky and moderate seas. The vessel was sailing in apparent winds of about 18 knots at a heel angle of about 10 degrees.

Slide 8: Animation Begins

Segment 1: 0-6s

The officer of the watch started to track several squalls and once he determined that the vessel would encounter one of them, he ordered the windward doors and windows to be closed against the rain.

Segment 2: 6-13s

However, as you can see by the red circles, the leeward doors, skylight and vents remained open. This had a significant impact on the sinking.

Segment 3: 13-22s

[Zoom out] As the squall got closer, the rain started and the wind increased. The vessel responded by heeling further and one of the students, gathering laundry, recorded a video.

Segment 4:22-36s

(Wait ‘till camera pans forward) The wind at this time was observed to be about 23 knots and the heel angle was approximately 23 degrees, which was just below the deck's edge. The officer of the watch did not call the master nor take action to reduce the heel angle.

Segment 5:

Next, the officer of the watch observed the wind speed increasing and shifting forward. The vessel started heeling further. Although he tried to remedy the situation by altering course, the vessel was knocked down. The last observed wind speed was around 30 knots.

Segment 6:

Once knocked down and with the deckhouse doors open and taking on water, recovery was impossible. The master, who was in his cabin, immediately went to the bridge and during the next 20 minutes the crew, faculty and students fought against time and the elements to abandon ship. The ship was equipped with 8 liferafts but, after the knockdown only 5 remained available.

Animation Ends.

Slide 9: Difficulties During Abandon Ship

A knocked-down vessel presents all sorts of problems.

Not only did the crew, faculty and students struggle to get out, but reaching the liferafts, and then launching them, was extremely difficult. Moreover, no distress alert could be sent because the room with the radio equipment was flooded.

Accounting for everyone on board was also difficult—to the point that the master could not even confirm that everyone had made it safely off the ship.

Slide 10: Post Abandonment

The Concordia was equipped with an emergency beacon which was designed to automatically transmit a distress signal should the vessel sink. Although this provided some level of comfort to survivors, they nonetheless endured difficult conditions while awaiting rescue over the next 41 hours.  These included seasickness, high winds and waves overnight, and water in the bottom of the rafts.

Slide 11: Search and Rescue

The emergency beacon was first detected and its position confirmed by shore stations approximately 1 hour after the knockdown. The location fell under the responsibility of Brazilian Search and Rescue.

The following morning, some 17 hours after the knockdown, Joint Rescue Coordination Centre Halifax received a fax from Maritime Rescue Coordination Centre Brazil requesting information regarding the Concordia, which triggered a Canadian response.

Following receipt of the fax JRCC Halifax contacted the school in Lunenberg, N.S. They also tried to contact the telephone number registered with the vessel's emergency beacon, but were unsuccessful.

Around 6 pm on February 18, authorities in Rio de Janeiro dispatched an airplane to the location of  the beacon. The rafts were spotted some 90 minutes later, or 29 hours after the knockdown.

Slide 12: Search and Rescue

Between 3 and 5 am on the morning of February 19th, two commercial ships, the Crystal Pioneer and the Hokuetsu Delight, arrived on scene and picked up the survivors from the liferafts [gesture]. This was approximately 41 hours after the knockdown. All survivors arrived in Rio de Janeiro the following day.

That concludes my brief synopsis of the events surrounding the knockdown of the Concordia and the rescue of her crew. We will now focus the presentation on several key aspects of the investigation.

Slide 13: Weather Analysis

As we said earlier, there was no single factor that alone caused this accident. That being said, however, there were a number of factors that played an important role, and one key element of the TSB's investigation was to determine, as clearly as possible, what the weather was at the time of the knockdown.

To do this, the TSB relied on video footage, as well as accounts from those on board. We also consulted with Environment Canada for analysis of the satellite imagery for the area.

Before discussing the results of the analysis, it would be helpful to briefly explain the mechanics of a squall.

Slide 14: Squall Defined

A squall is a weather system which produces downdraft winds reaching the earth's surface. The strength of a downdraft is dependent on the storm's structure, the intensity of the main updraft, and other factors. A strong downdraft which produces an outburst of damaging winds at or near the surface is known as a downburst.

A downburst that is localized and intense is called a microburst and generates winds ranging from 50 - 150 knots. Microbursts are associated with a significant drop in air temperature.

Slide 15: Probable Wind Speed

During the field phase of the investigation, there were no observations of wind speeds in excess of 50 knots, nor an air temperature change.

The Environment Canada analysis also indicated that the weather system in the area at the time was both weaker and less organized in comparison to known microbursts.

In fact, as we said earlier, it is very likely that conditions were no worse than what Concordia must have survived many times before. The vessel, however, was vulnerable in certain combinations of sail plan and weather —a fact the officer of the watch was unaware of. I will now turn to Ms Fyfe who will discuss the vessel's limitations and the significance of the guidance information that was on board.

Abby

Slide 16: Stability Assessment

After all the information was gathered from the witnesses there was no one factor that stood out as being the likely cause of the accident. It was quickly decided that a close examination of the vessel's stability was needed to fully understand what happened that day. There was a lot of information available, such as ship's plans, stability booklet, and the video. This was used to create a computer model of the vessel and to perform the calculations which were then validated against observations of the ship's behavior on the day of the occurrence. The details of these calculations are presented in the occurrence report, but for the purpose of this presentation I will focus on the information that was available to the crew to guide them in situations such as the Concordia encountered.

Slide 17: Vessel Stability Limits

All ships at sea and underway have limits. Perhaps most critical are those limits that relate to their stability or their ability to remain upright in the water. For example, everyone knows that if you load a ship with too much cargo it can sink just as it will if you fill it with water. Similarly, if cargo gets loaded too high on a ship you are at risk of tipping over.

Slide 18: Sailing Vessel Limitations

Sailing vessels are no different, however, their key stability limit is that of achieving the delicate balance between the force of the wind and the vessel's inherent ability to remain upright in the face of that wind.

The force of the wind is shown as the yellow arrow pushing the vessel over. The magnitude of this force will depend on the wind speed and direction as well as the amount of sail the ship is carrying.

Counteracting the force of the wind is the buoyancy of the ship, which brings the vessel back towards the upright when it is being heeled over. The amount of buoyancy force depends primarily on the shape of the hull.

A sailing vessel will usually sail at an angle where the force of the wind equals the righting ability of the ship, as demonstrated in the slide.

As mentioned earlier, squalls, such as the one encountered by the Concordia, may include winds which, rather than blowing horizontally over the ocean, are inclined.

This would have the effect of heeling the ship further even if there is no increase in the wind speed.

Now, if we return the sailing vessel to its previous balanced position in horizontal winds we will demonstrate another aspect of sailing vessel stability. As a ship heels over it may reach a point where the balance between wind force and buoyancy is more difficult to achieve.

If this point is reached a small increase in wind speed will cause the ship to heel over significantly before it can regain that balance. The investigation found that under the conditions on the day of the occurrence the Concordia would have reached this point in winds between 27 and 37 knots which would have pushed her over to almost 70 degrees.

Considering that at sea the winds are constantly and sometimes unpredictably changing information about this limit is critical to the crew.

Slide 19: Guidance Information

When ships are built, naval architects do tests and calculations in order to prepare a book which is used by the crew to guide them with respect to the ship's stability limits. For example; a typical cargo ship will have a book which details how much cargo can be safely loaded and how it may be distributed among the holds.

Guidance information for sailing vessels should provide the crew with information they can use to assess their risk of knockdown in various weather conditions.

Slide 20: Concordia’s Stability Limits

Concordia had a stability book that contained this type of information.

Most directly, the book stated that the maximum safe steady heel angle in typical gusting conditions was 24 degrees.

Analysis of the video that was taken in the minutes prior to the knockdown indicated that the vessel was sailing at around 23 degrees at that time.

Slide 21: Squall Curves – Margin of Safety

The stability book also provided the crew with something called "squall curves." To use these curves, an officer needs to know the vessel's steady heel angle and the apparent wind speed. Based on this, he or she can then determine the maximum wind speed at which the vessel will remain safe if the sail plan and heading are maintained. By comparing that with the current wind speed the officer can determine the vessel's margin of safety.

Examination of the Concordia's squall curves indicated that its margin of safety was decreasing as the squall approached. Specifically, the squall curves show that the vessel would be safe only until the wind speed doubled. However in a squall, winds are known to increase by as much as 10 times.

In other words, the information on board the Concordia was indicating that the vessel was at risk and that action was required to reduce the ship's heel angle—either by reducing sail or changing heading.

However, the investigation determined that the officer of the watch was not aware of this information.

I will now hand it back over to Member Seymour who will speak to the report's findings, the primary safety issues and the recommendations the Board is making today. Member Seymour.

Jonathan

Slide 22: Findings as to Cause

As described by Ms. Fyfe, Concordia was in a situation where reducing the amount of sail and changing the vessel's course were necessary to increase the margin of safety before the onset of the squall.

But the officer of the watch had not been familiarized with the squall curves since joining the vessel. They were not discussed at the handover of the watch, he had never been trained in their use, and there was no guidance from management in this respect.

Consequently, sail was not reduced and the attempt that was made to change course came too late.

Furthermore, because the officer of the watch did not believe that the squall represented a threat, doors, windows and other watertight openings were not closed.  Consequently, when the vessel was knocked down, it quickly flooded, and the Concordia lost any hope of righting itself.

Slide 23: Findings as to Risk

The Board also made a number of findings as to risk, which address such topics as knockdown preparedness, equipment familiarization, EPIRB registration, search and rescue issues, and safety management systems.

Slide 24: Safety Issues

Now I will address the key safety issues identified during this investigation.

The Concordia had squall curves on board which, if consulted and acted upon, would have resulted in mitigating action. This information was to hand because the Bahamas, the original flag state, required that it be provided.  Canada and the UK also have this requirement. But many other flag states do not.

In this accident, the information was available, but the officer of the watch was not aware of its significance, was not familiar with it, and had not been trained in its use.  This situation appears to be prevalent worldwide.

Both of these issues – the provision of squall curves and awareness and familiarization need to be addressed.  Firstly, the Board looked at the situation in Canada then, secondly, worldwide.

Slide 25: Recommendation 1 - Canada

The investigation examined Transport Canada's regulatory requirements for sail-training vessels and found a significant gap: Yes, squall curves must be provided, but officers are not required to demonstrate competency in using this information. That is why the Board is recommending:

The Department of Transport ensure those officers to whom it issues sailing vessel endorsements are trained to use the stability guidance information that it requires to be on board sailing vessels.

Slide 26: Recommendation 2 - International

Sail training is international. This investigation determined that only a limited number of countries require vessels to carry squall curves. Furthermore, no flag state requires officers to be examined in their ability to use this type of information.

As an authoritative flag and port state, Canada is well placed to take a leading position in advocating for worldwide standards at the International Maritime Organization and Sail Training International. Therefore the Board is recommending that:

The Department of Transport undertake initiatives leading to the adoption of international standards for sail training vessels on the provision of stability guidance to assist officers in assessing the risk of a knockdown and capsize, and for the training of officers in the use of this information.

Slide 27: Action Required

In summary, these two recommendations are aimed at moving the sail training industry towards the position where all vessels have squall curves (or equivalent) on board, and all deck officers are trained in their use.  If adopted, the likelihood of a knockdown and capsizing similar to that of the Concordia will be much reduced.

That concludes our presentation.