KEY POINTS:
A fishing vessel which sank, killing six people in one of New Zealand's worst maritime tragedies, was not fit to be at sea, but slipped through a failing inspection regime that is also putting other ships at risk, a damning report says.
The investigation into the disaster involving the Kotuku, in Foveaux Strait in May 2006, which killed members from three generations of Bluff's Topi family, is being described as a "sentinel event", warning of larger problems in the regulation of boating that must be fixed "once and for all".
"It is all too clear that the dead, the survivors, and their families were failed by a marine regulatory system that should not have allowed Kotuku to be at sea," said Transport Accident Investigation Commission (TAIC) chief commissioner Bill Jeffries.
Three of the nine people on board managed to swim to safety after the boat capsized, but inadequate life-saving devices on board and consumption of alcohol and cannabis also limited the chances of survival for some, the report said.
The owner of the Kotuku and a survivor of the sinking, John Edminstin, claims the TAIC report is selective, and laden with errors. "I don't know how they can all get away with it."
The report said the Kotuku was inspected for safety for all but the first three years of its 43-year life, but problems were not picked up.
The 14m-long vessel should not have been licensed to go to sea because of the "poor condition" of the hull, questions over its stability and an inability to shed water when it became flooded.
Maritime New Zealand and inspectors had been working with "and patching up an unsatisfactory and unevenly applied ... system for too long", Mr Jeffries said. "Commercial pressures and a culture that excuses shortcomings appear to have permeated ... the inspection system ... at the expense of good seamanship, safety and lives."
Maritime New Zealand said progress was well under way in following a series of safety recommendations made by TAIC in the report, including improvements to its Safe Ship Management (SSM) System.
"What is clear from TAIC's report is that a number of factors combined to cause this accident, which everyone can learn from," said Maritime New Zealand director Catherine Taylor.
Mr Edminstin said what he had read of the report was "full of mistakes" and he believed the Kotuku was seaworthy. He was particularly scathing of the TAIC lead investigator, Captain Doug Monks, claiming he had "shopped around and got people to back him up".
He did not want to elaborate on the errors, saying he wanted to wait to see what Maritime New Zealand had to say in its report.
HOW THE TRAGEDY UNFOLDED
* The fishing vessel Kotuku and three crew travelled from Stewart Island to the nearby island of Kaihuka on the morning of May 13, 2006, to pick up six members of the Topi family who had been gathering muttonbird.
* After loading up the Kotuku with 1000kg of muttonbird and equipment, it headed through Foveaux Strait towards Bluff.
* Between 2.15pm and 2.30pm, the Kotuku was hit by two large waves and the vessel was flooded and capsized.
* Leslie (Peter) Topi, his daughter Tania Marie Topi, 41, and his two 9-year-old grandsons, Shain Topi-Tairi and Sailor Trow-Topi were trapped in the upturned hull and died.
* The vessel's owner, John Edminstin, and his friend Ian "Shorty" Hayward, grabbed hold of some floating cargo. Clinton Woods, 34, Paul Maurice Topi, 46, and his nephew Dylan James Topi, 16, climbed on to the upturned hull before being forced to try to swim to shore.
* Only Mr Edminstin, Paul Topi and Dylan Topi made it to nearby Womens Island alive. It was after 7.30pm before the trio were rescued.
* It was the worst maritime disaster in New Zealand since the sinking of the Wahine 40 years ago.
INVESTIGATION FINDINGS
* The Kotuku was not seaworthy, and should not have passed inspections. The inspection regime for all similar vessels in New Zealand is now under scrutiny.
* The right number and type of lifejackets were not on board the ship, and were inaccessible in a cabin.
* A liferaft on board did not come free as it was supposed to after the Kotuku capsized.
* Alcohol sped the onset of hypothermia for two of those who died. Cannabis use may have been a factor in one crew member's death.
* The search for those on board may have started earlier if marine radio had been used instead of a reliance on mobile phones.
BLAME MIGHTY SEA, NOT THE CAPTAIN, SAYS VICTIM'S WIFE
A family devastated by the Kotuku sea tragedy are not convinced the vessel was unfit to be at sea.
Bluff man Ian "Shorty" Hayward, a close friend of the vessel's owner, John Edminstin, was one of six who died after the Kotuku capsized in Foveaux Strait.
Despite the best efforts by Mr Edminstin to help him, Mr Hayward was unable to reach nearby Womens Island with the three survivors.
While a damning report from the Transport Accident Investigation Commission said the Kotuku should never been allowed at sea, Mr Hayward's widow, Judy Hayward, said her husband had "all faith" in Mr Edminstin when he joined him on a trip to pick up a local family that had been hunting muttonbird.
"He would never have gone out if he thought the boat was defective, or indeed if he thought it was unsafe or 'unseaworthy' as the report suggests. How absurd," Mrs Hayward said.
"He went on a social outing like many people do every weekend around the country. He had a great time with his friends [and] unfortunately he did not come home to us.
"We will always have faith in our friend John. It was such a tragedy for everyone involved and no amount of preparation can prepare for all of the elements of the mighty sea."
Mrs Hayward said there was nothing in the report that proved "beyond a shadow of a doubt" the Kotuku's failings were the cause of the tragedy.
"Hindsight is a great thing. There are a lot of suggestions for improvement for the entire industry, but who does this responsibility begin or end with?
"This accident will become the scapegoat for change in the industry hiding years of neglect and mismanagement.
"Was that the outcome that was behind it all?"
