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NARRATIVE

On 7 June:

Around 5.30 am. The skipper of CARRERA confirmed to his friend his intention to go out to sea for "a fishing haul", the latter tried to dissuade him from doing so because of the weather forecast.

Around 6.30 am CARRERA sailed for shrimp fishing, probably in the Bourgenay sector. The skipper was alone on board. On leaving the port, he activated his foghorn to signal his passage. At that time, he was not wearing a PFD over his sea clothing. He had one brief telephone contact with his wife. He was the only vessel to depart that day.

Between 10.00 am and 10.15 am the CARRERA's skipper called his friend to tell him that he would be back between 10.45 am and 11.00 am. He asked him to go and check the sea state in the fairway.

At about the same time, the tenured skipper of JACK MORISSEAU called the skipper of CARRERA to find out his intentions. He told him "you won't be able to return (to Les Sables d'Olonne )". The CARRERA's skipper answered on the contrary "that he will be able to go back." The skipper of the lifeboat then advised him to "take shelter from the south westerly winds in the Pertuis" (the Pertuis Breton, a coastal area in the south of Les Sables d'Olonne, is sheltered from southerly winds by the Île de Ré  although the maximum altitudes are around twenty metres). The conversation did not continue and the tenured skipper of JACK MORISSEAU alerted the other crew members to the impending departure.

At 11.11 am the signal from CARRERA's first emergency beacon was received by one satellite in the Cospas Sarsat constellation.

At 11.13 am Cospas Sarsat message received by Gris Nez MRCC. The position received was inland, north of Les Sables d'Olonne.

At 11.18 am the Étel MRCC was contacted by the radio of JACK MORISSEAU who informed it of the situation using the jargon of the trade "there is no more fairway here." There followed a moment of incomprehension which was quickly corrected. The MRCC, already in great demand because of the storm, asked JACK MORISSEAU for clarification to take into account the CARRERA problem.

At 11.20 am Étel MRCC was informed of the triggering of the CARRERA's beacon by Gris Nez MRCC. Étel MRCC transmitted the information to JACK MORISSEAU.

At 11.21 am Gris Nez MRCC received the first confirmed position of one of the CARRERA's beacons. At the same time, Étel MRCC "launched" JACK MORISSEAU to “try to meet CARRERA."

At 11.26 am the Étel MRCC broadcast a Mayday Relay to alert vessels in Les Sables d'Olonne sector to assist CARRERA.

At 11.27 am the Étel MRCC recorded inaudible sounds and voices (this recording corresponded to the moment when JACK MORISSEAU was hit by the wave that broke two front windows, the VHF having remained in transmit mode).

At 11.28 am JACK MORISSEAU informed the Étel MRCC of his distress situation. Shortly afterwards, while the acting skipper was trying to maintain a course appropriate to the sea state, JACK MORISSEAU capsized under the effect of a high wave.

At 11.34 am second Mayday Relay, an alert to all vessels, which this time concerned CARRERA and JACK MORISSEAU.

At 11.35 am the fishing vessel MANBRISA proposed to the Étel MRCC to sail (from Les Sables d'Olonne). The MRCC warned her several times about the risks due to the sea state.

At 11.36 am JACK MORISSEAU was signalled "overturned" by a witness onshore at the beach of Le Tanchet. The information was confirmed shortly afterwards by other witnesses onshore. The attempt by the MRCC to call the lifeboat remained unanswered.

At about the same time, a person driving on waterfront promenade, saw "a small fishing boat with a white cabin", in the direction of the Le Nouch Sud buoy. Badly shaken by the waves, she disappeared after turning back.

At 11.38 am MANBRISA advised another fishing vessel, also alongside, that it was not possible to go out.

At 11.49 am an initial report on the situation of the shipwrecked was transmitted to the MRCC by the shore based rescue services.

The radio managed to extract himself from the lifeboat after removing his manual inflatable lifejacket, which he had then used as a buoy.

From 11.56 am the acting skipper of JACK MORISSEAU managed to get in touch with the MRCC using his mobile phone. He found refuge in the engine room, but cannot stay there any longer for fear of being asphyxiated. He then moved to the other compartments for investigation. He endeavoured to preserve the buoyancy of the lifeboat by closing the watertight doors as he made his way to the forward quarters, from which he was extracted at 0.36 pm by the rescuers.

At 0.58 pm the final assessment of the rescue operations carried out by the shore teams was transmitted to the MRCC.

Under the effect of the waves and the tidal current, the overturned hull of the lifeboat was driven ashore. Two days after the accident, the wreck was destroyed by a machine.

On 16 June 
The body of the CARRERA s skipper was found on the beach in Les Sables d'Olonne. The identity of the sailor has been confirmed by an autopsy and DNA analysis.

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FOCUS ON SITUATION OF CREW DURING FINAL CAPSIZING

* When the lifeboat capsized, four crew members found themselves almost immediately overboard Submerged by the breaking waves, three of them made it safely ashore, but the fourth did not survive the ordeal.

* The other three crew members were trapped in the overturned lifeboat and almost completely flooded The engine room, isolated from the rest of the lifeboat by watertight doors, was not flooded, but the air in it was difficult to breathe Of these three men, two died by drowning shortly after the lifeboat capsized only one man was rescued unharmed by a land rescuer who managed to get in through the after escape hatch of the lifeboat.

* When the water entered the wheelhouse, all the self activating PFDs inflated, including those in reserve, suspended to a rod The wearing of a PFD with automatic activation, which has been proven to be effective in the event of a man overboard, is hindering in an enclosed space invaded when capsized The only crew member not wearing one in the lifeboat would not have been able to return to shore without a buoyancy aid, in this case, buoy Silzig which was given to him by the radio.

* Of the survivors who reached the shore, two were wearing wetsuits and were equipped with manually activated personal flotation devices (without crotch straps (not SNSM’s current model) They could only escape drowning by removing them because they were rising above their shoulders.

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CONCLUSIONS

1/ The trawler CARRERA departed while a BMS issued the previous day by Météo France was in progress.
The decision to sail was due to a lack of safety culture on the part of the CARRERA's skipper. The skipper of the CARRERA was alone on board even though his licence required him to have two crew members on board; a crew member could have questioned his decision to depart. CARRERA foundered before the inaccuracies in her position were resolved.

2/ The first intention of the AWL JACK MORISSEAU was to direct the research towards the north west of Les Sables d'Olonne; this hypothesis could not be verified by Étel MRCC.

3/ The AWL JACK MORISSEAU, therefore, agreed to sail, in very difficult sea conditions, at the request of Étel MRCC, for an imprecise search area.

4/ The AWL JACK MORISSEAU and air assets were unable to locate the skipper of CARRERA before the search was suspended on the evening of the accident. The only nautical means to have been mobilized by the Étel MRCC was the AWL JACK MORISSEAU who had
been pre-positioned in the outer port of Les Sables d'Olonne.

5/ Comparative tests carried out by the equipment manufacturer Houdini Marine on new glass and glass from an AWL JACK MORISSEAU sister ship, show that today’s glasses are much more resistant to impacts caused by waves. The ageing of the sealant has almost certainly had a negative influence on the resistance of the windows.

6/ Because of the vessel's design, with no bulkhead between the wheelhouse and the forward quarters, the study shows that the righting capabilities of the AWL JACK MORISSEAU were greatly exceeded by the extent of the rolling motion when the wheelhouse was flooded.

7/ The electrification of the metal structure of the wheelhouse space degraded the crew's ability to act before the capsizing.

8/ When the AWL JACK MORISSEAU capsized, the seven crew members were faced with situations that SNSM crews are not trained to deal with: being trapped in a capsized lifeboat and submerged by seawater, with men overboard having to deal with breaking waves of 4 to 5 metres.

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BEA MER FINAL REPORT ‘S EXTRACTS

Safety Lessons

1. 2020-E-XX: the glass, sealant, and structure assembly loses some of its initial resistance over time.

2. 2020-E-XX: current assembly techniques offer more "elasticity" to the frame-glass assembly, and therefore a better capacity to absorb the shocks caused by the waves.

3. 2020-E-XX: French regulations, dealing with the bridge windows of surveillance and rescue vessels, do not take account of the particularly exposed conditions to which such vessels may be subjected. The provision concerning the fitting of dead covers appears in practice to be ill-adapted.

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Safety Recommendations

Given the measures taken by the SNSM, BEAmer further recommends:

To the SNSM:

1. 2020-R-XX: to replace, as much as operational constraints allow, windows which are not of tempered glass by laminated and tempered glass on board all-weather boats.

To the administration:

2. 2020-R-XX: to encourage operators to define the limits for the use of rescue vessels, especially when they are exposed to the risks inherent in interventions in particularly difficult weather conditions.

3. 2020-R-XX: to change the regulations to take into account the findings made in this report regarding the thickness and nature of glass windows on rescue vessels.

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SNSM ACTIONS TAKEN

Short term:

A/ Creation of a working and reflection group on the role and responsibilities of the skipper, including decision making before and during interventions.

B/ Examine the structure of AWLs SNS062 to SNS066 to study possible strengthening of central reinforcements.

C/ Carry out a campaign of window thickness measurements on all older generation AWLs, and possibly, in a second stage, on the other launches.

D/ Coordinated action with the BEAmer

E/ Equip the old generation AWLs with light and removable bulkheads on the companionway to the forward quarters, to limit massive water flooding.

F/ Creation of a working group on PFDs to determine best practices regarding their wearing in wheelhouses and to decide on the possible integration of accessory equipment. This group will also examine the risk for a crew being trapped in a capsized ship.

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In the longer term:

WG5 will carry out, within the framework of the specification (future fleet), a study of the degraded situation in the event of water flooding the wheelhouse. This will concern the rapid evacuation of water as well as the watertightness of the engine and helm controls

More generally:
- Measure and limit the effects of 220 V in the event of water flooding the wheelhouse. 
- Implementation of a "retex" (feedback) applying system.
- Review the stowage of equipment (motor pumps, diving blocks, etc ...) in wheelhouse.

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