Chain of Events An examination of the events leading up to, and resulting from, the 67 foot fall of a trainee from th

1. Chain of Events An examination of the events leading up to, and resulting from, the 67 foot fall of a trainee from the rigging of the Lady Washington. Capt. Les Bolton, Executive Director, Grays Harbor Historical Seaport Authority Co Chair of the ASTA Technical Committee – les@historicalseaport.org

2. May 20, 2006 - 18:30 hrs. Weather: Sunny & Warm Wind: 18 kn. W. Sea State: Calm Departing Port of Ilwaco, Washington in the Columbia River for a 3-hour sail with the public. Lady Washington was following Hawaiian Chieftain out of the marina channel under slow motor as the crews of both vessels went aloft to cast off gaskets.

3. Contributing Factors • A family medical emergency resulted in the unplanned departure of our regular Senior Master one week earlier than was originally planned. • A short-term Relief Master was brought in. (Very competent and capable.) • This Relief Master had worked for us in the past, but was not completely familiar with our organizational protocols, or the capabilities of this crew. • It was the Relief Master’s last sail before turning over command. • There were 48 passengers onboard (an audience). • A Trainee requested permission to lay aloft to the pole top and touch the main truck after casting off and coiling the topgallant gaskets.

4. Contributing Factors • Although this was out of the ordinary, particularly for a trainee, permission was granted. • Passengers were made aware that something unusual was going to be happening. • Trainee climbed aloft, cast off and coiled gaskets.

5. Contributing Factors • All eyes were aloft making it more difficult for the trainee to change his mind, increasing pressure to perform.

6. Contributing Factors • Trainee climbed to the pole top and made an unthinking mistake. • He clipped into a Backstay. • As he began easing himself down he slipped, lost his grip and fell . . .

7. Mechanics of the Fall • As the trainee fell, still clipped into the backstay, he did attempt to catch himself. • A crewmember on the topyard twenty feet below heard him as he began to fall, grabbed into the topyard jackstay, reached out and grabbed the trainee’s harness lanyard. Although he could not hold the trainee, he did slow the fall and change the trainee’s trajectory, causing him to swing in toward the mast at a reduced speed. • Twenty feet lower the trainee struck the main top with such force that he spun full circle as he continued his fall. This impact again reduced his rate of decent. • Twenty-four feet lower, falling inboard he struck the starboard rail cap and pin rail, breaking a belaying pin with his jaw and cheekbone before falling inboard striking the deck very lightly with his head and feet. His torso was suspended approximately six inches off the deck by his harness and lanyard, still clipped into the backstay. He was alive, conscious, in extreme pain, bleeding from his head, face and hands.

8. Our Emergency Response and other factors that improved our potential for a positive outcome • Upon losing his grip on the harness our topman sounded the alarm “ALL HANDS.” • Mate called “Hands to emergency stations.” • We drill often. • We were fortunate that he fell inboard. Our backstays run outboard to the channels. He could have been hanging outboard below the channels.

9. Our Emergency Response and other factors that improved our potential for a positive outcome • Master focused on vessel operation & VHF 16 call – Situation & location • Mate called 911 on ship’s cell phone – Situation, location victim status, requested closest/best transferpoint for 11 foot draft. Passed off phone to medical team. • Senior Medical officer requested assistance from passengers (two nurses on board) • First aid response team have First Aid kit, trauma kit, cervical collars backboard and blankets on deck in minutes. Set up visual screen, assisted as required. • Steward informed passengers that we have had an accident and need their cooperation. Cleared the aft deck and approaches requesting passengers move to the port bow. Began singing to calm passengers and mask sounds from aft deck. • Mate directed idle hands to prepare for receiving USCG first Responder on the port side and prepare for mooring dockside on the starboard side. • Idle hands assist Steward with passengers, checking on them, join in singing.

10. Our Emergency Response and other factors that improved our potential for a positive outcome • USCG First Responder was a shipmate, left two days before. Very reassuring - He knew what to expect, what he would and would not need to transfer. • Victim was secure on our backboard before EMT’s boarded. All hands were standing by to transport victim over the side on to the gurney. • Mate gathered victim’s wallet, passport, address book, medical forms and day pack.

11. Our Emergency Response and other factors that improved our potential for a positive outcome • Mate assigned to travel with victim – carried victim’s daypack, personal documents, crew record and a cell phone. (Forgot charger) • Master – Apologized to passengers, explained the need to follow specific protocols and asked for their patience. He assured passengers that they would all receive full refunds. • Crew Muster – Aft deck

12. Immediate Post Incident Response and other factors that improved our potential for a positive outcome • CREW MUSTER – Assessment and assignments • Status Reports – Each Crewmember and vessel general • Greatest need is to stay focused, be vigilant, don’t make mistakes. Focus on your job, do your job, return to the ship. NO comments, NO visitors, NO shore leave. • “Mate is with our shipmate, he will keep us posted.” • Set up ramp for disembarking passengers • Two crew to attend to passenger refunds and check passenger emotional state. • Crew member assigned to collect names and contact information of eyewitnesses. • Idle hands to clean up, furl, stow and wash down. Save & tag related equipment. • Muster in one hour

13. Immediate Post Incident Response and other factors that improved our potential for a positive outcome • Executive Director – Established asONLY media contact for this incident. • While driving - calls to Marine Operations Committee Chair and Insurance Agent – Advised of situation will keep updated as new information is available. • Met with Master for quick overview. • Met reporters on site – Confirmed that there was an accident. Passed out business cards with cell phone number written on back, collected press cards - “Our crew did an excellent job of responding to a very distressing accident. They are very concerned about their injured shipmate and they just need some time to process what has just happened. I will keep you informed as we know more.” • Marine Operations Manager – Making arrangements for testing. • Crew Muster to review accident, and current status.

14. Immediate Post Incident Response and other factors that improved our potential for a positive outcome Crew Muster • Address Trauma - Terrible accident – Excellent response – Your shipmate is alive • Full accident review by Master and crew - Marine Operations Manger takes notes. • Recognized the positive actions of each crewmember and the cumulative positive effect that had on the fate of their shipmate. • Discussed the seriousness of the accident and the need to follow established protocols. • Questions and answers. • Requested all hands to quickly write out where they were, and what they remembered of the sequence of events leading up to, and following the accident. • Master to fill out organizational “Incident Report Form”, form CG2692 and ensure a complete log entry as well. • Marine Operations Manager responsible to transport crew for testing.

15. Organizational ImpactMaking Lemonade Lukas Watch • We were fortunate that our schedule called for the ship to be in the Portland area three days later. Spending four hours with our injured shipmate at the regional trauma center was placed as a voluntary option on the duty roster. Crew were there 8 to 12 hours a day, every day, for the next two weeks. Good for him; Great for our crew.

16. Organizational ImpactMaking Lemonade Controlling the Message • We established a written public statement, posted at all office phones, on both boats and e-mailed to all Board and Marine Operations Committee members. • A trainee fell from the rigging the Tall Ship Lady Washington last Saturday evening as the ship was departing Ilwaco on a three-hour public sail. • The trainee was stabilized and immediately transported to a regional Trauma Center in Portland. • We are very thankful for the quick action of the ship’s crew and local emergency personnel in responding to this unfortunate accident. • As we have more details, we will make them available to you. • We were able to follow up later with factual details and positive “spin”.

17. Organizational ImpactMaking Lemonade Internal Review Process • Ships met with Executive Director and Marine Operations Manager to discuss and establish strict interim operating parameters for trainees and paid staff. • Marine Operations Committee met with all senior staff, and officers of both vessels to review the accident and our response, what we did right, how we could have improved our responses. • Evaluated other emergency scenarios and our readiness to react quickly and effectively. • Evaluated our crew training protocols and our training documentation. • Reviewed and reestablished appropriate written operational parameters for trainees. These meetings were the most well attended and productive Marine Operations Committee meetings that we have ever had.

18. Organizational ImpactMaking Lemonade Weaknesses were identified, and plans were made to address those weaknesses. • Trainees Aloft – Work stations were identified. No unaccompanied trainees beyond work stations. Additional training/review required beyond work stations. • Trainee Checklist – Develop a new progressive learning checklist that documents and encourages Trainee advancement and becomes part of the Trainee’s permanent record. • Crew Training - Set aside EVERY Monday after 15:30 for crew training – NO Public • Crew Training - Schedule at least one “911” Cross Training per year. • Safety Gear - Immediate inventory, evaluation and review of harnesses and Lanyards. • Rig modifications - Lay-up traveler on Royal Poles. Attach baggywrinkle where main yard intercepts backstay.

19. Organizational ImpactOutcomes • Rig modifications – Completed • Safety Gear – After much research and discussion it was determined that most of our gear was designed for light/recreational duty, some of our systems were mismatched (fall arrest/fall protect) and none of them met industry standards for cut-away rescue. • Research and negotiations resulted in the purchase of a new system based on the PETZL Navaho seat harness with double poly-dac lanyards and SS locking carabineers for each crewmember, plus four PETZL Chester (Quick converter to full body harness) for each vessel. • Crew Training - EVERY Monday after 15:30 is set aside for crew training – NO Public • Crew Training - “911 Cross Training” is tentatively scheduled for last week in June. • Trainee Checklist – DRAFT 3 is currently in use aboard both of our vessels.

20. Organizational ImpactOutcomes Trainee Checklist – DRAFT 3 (currently in use) - Final DRAFT - #4 is near completion Day One • Sign Aboard Checklist – (3 Items) • Vessel Orientation Checklist – (8 Items) • Basic Safety Orientation Checklist – (6 Items) Week One • Essential Tools Checklist – (3 Items) • Basic Knots Checklist – (6 Items) • Docking Protocols Checklist – (4 Items) • Dockside Tour Operations Checklist – (5 Items)

21. Organizational ImpactOutcomes Week Two • Dock Lines Checklist – (5 Items) • Sail Theory Checklist – (3 Items) • Advanced Knots Checklist – (2 Items) • Lookout Checklist – (3 Items) • Helm Checklist – (3 Items) Safety Checklist – To be completed ASAP - Required for consideration as a “Topman” • Harness Checklist – (6 Items) • Pre - Aloft Checklist – (11 Items) • Aloft Checklist – (6 Items) • Deck Checklist – (10 Items) • Advanced Safety Checklist – (6 Items)

22. Our Future ?