Transport Accident Investigation Commission iCatcher accident.
Final report on the Charter fishing vessel, i-Catcher, capsize, Goose Bay, New Zealand, 10 September
Five people died after a whale capsized the i-Catcher boat near Kaikōura during a birdwatching trip.
The Transport Accident Investigation Commission’s report highlighted lifejacket issues and a leaking fuel system.
Seven safety recommendations were made to improve emergency responses and maritime safety practices.
Police say tragedy “important for us all to learn from”.
Details of how five people died after their charter boat struck a whale and capsized near Kaikoura during a birdwatching trip have been revealed today by the Transport Accident Investigation Commission.
And seven recommendations to New Zealand’s emergency services in a bid to “resolve six major safety issues” identified by TAIC investigators following the tragedy.
On September 10, 2022, 11 people were on the i-Catcher commercial vessel on a bird-watching trip.
The sea was flat and calm, but disaster struck near Goose Bay when a whale surfaced directly underneath the boat, capsizing it.
The group had seen two humpback whales shortly before the fatal incident.
“The skipper stopped the vessel and turned the boat around so that passengers on either side of the boat could photograph the whales in the distance,” the report revealed.
After the deadly collision, skipper Mark Ealam and five passengers were rescued from atop the boat - but five others were found dead in an air pocket beneath it.
The capsized vessel.
They were Catherine Margaret Haddock, 65, and Susan Jane Cade, 63, of Lower Hutt, Diana Ruby Stewart, 68, Peter Charles Hockley, 76, and Maureen Patricia Pierre, 75, of Christchurch were all killed on September 10, 2022.
The fatal incident has been under investigation by TAIC and today the final report was released.
“All five [victims] were wearing inflated lifejackets in the air pocket, which was heavily contaminated with petrol fumes, the result of a defective and leaking fuel system,” said Chief Investigator of Accidents Naveen Kozhuppakalam.
“Survivability was reduced by the combination of a toxic environment, cold water, and the confined space.”
Image / Supplied
The TAIC report is 90 pages long and covers what happened at Goose Bay, why it happened, what can be learned from it and who may benefit from those lessons.
Today, Chief Commissioner of TAIC David Clarke acknowledged the release of the report would bring back unwanted and upsetting emotions.
But the point of the investigation and report, he said, was to identify the cause of the incident and highlight any safety issues that “could be the difference between safety and tragedy” in a future event.
All of the occupants of the boat survived the initial capsize, TAIC confirmed.
i-Catcher owner and skipper Mark Ealam and his wife Sharlene released a statement this afternoon.
“We appreciate the time taken to thoroughly investigate this terrible tragedy and we thank all of the organisations who worked on this final report by the Transport Accident Investigation Commission,” they said.
“We acknowledge and appreciate the recommendations, but it is not our place to comment on them. We are sure they will help improve safety on our waters.
“We can only hope that with this final report and its recommendations that people can somehow find some closure and move forward with their lives.
“It has been an awful time for all those involved, and our thoughts and condolences are again with the family and friends of those who died, and with those who survived.
“As we did in September 2022, we would ask for privacy for our family, as we relive our grief and mourn.”
Kozhuppakalam said the report highlighted nationwide and international safety issues that “require the attention of New Zealand’s emergency rescue sector, emergency equipment designers and manufacturers, and maritime regulators”.
FINDINGS
TAIC listed findings in the report. The main points include:
It is virtually certain the vessel capsized as a result of coming into contact with a whale that had surfaced under the port side of the vessel.
All 11 people survived the initial capsize, five of whom later died because of one or a combination of the following factors: exposure/inhalation of petrol fumes, time immersed in the 10C water and being confined in a toxic space.
The survey system did not require inspections of fuel systems and therefore couldn’t provide assurance of the integrity of the system.
Given the number of design approval requirements that were not met by the i-Catcher fuel system and the absence of documented reasoning of why the requirements were not met, it is very unlikely that the fuel system was thoroughly examined during the initial survey.
It is unlikely that the vessel’s fuel cap contributed to the fuel leak within the air pocket of the upturned vessel.
It is virtually certain that flaws in the vessel’s fuel system allowed fuel to leak into the air pocket of the upturned vessel, reducing the survivability of the accident.
The commission inspected the inflatable lifejackets worn by all passengers and identified that six had not met the servicing requirement set out in the Maritime Rules. On one of these lifejackets, the CO2 cylinder had corroded to a point where significant pitting had developed in the wall of the cylinder. This level of corrosion posed a significant risk to any user as the canister was at risk of failing while pressurised.
Kaikōura, an area of significant maritime activity, did not have a rescue plan, leaving the area susceptible to a disorganised emergency response.
Opportunities were missed to involve the dive squad at the outset of the (incident) provide early advice in sourcing local divers and consider an earlier deployment.
TAIC’S RECOMMENDATIONS
The commission issued a number of recommendations to Maritime NZ and police.
“In the interests of transport safety, it is important that recommendations are implemented without delay to help prevent similar accidents or incidents occurring in the future,” said Clarke.
“As Fish Kaikoura is no longer operating, the commission has not made any recommendations to it as the [i-Catcher] vessel operator.”
WHAT HAPPENED?
The passengers were members of the Nature Photography Society of New Zealand and had chartered the vessel for a three-hour passage to take photographs.
At about 10.05am they were on their way back to land when they “ felt a sudden impact from underneath the hull and the i-Catcher rapidly capsized”.
“Five passengers and the skipper managed to climb on top of the upturned hull, while the other five passengers remained in an air pocket underneath the vessel,” the report states.
“The skipper placed an emergency 111 call using a passenger’s mobile device, alerting police to the accident, and initiating a search and rescue operation.”
TAIC said it was “virtually certain the i-Catcher struck a whale”.
The report stated:
“All five deceased passengers were found within the air pocket under the upturned hull wearing inflated lifejackets, hindering their ability to escape.
“Four of the lifejackets were manually activated, while one was automatically activated.
“It is virtually certain that defects in the vessel’s fuel system allowed fuel to leak into the air pocket of the upturned vessel, reducing the survivability of the accident.”
Kozhuppakalam spoke further about the deaths today.
“Getting thrown into water is stressful, debilitating, and disorientating. If you surface in a confined space and you’re wearing a life jacket, you’ll want to swim underwater to escape,” he said.
“The commission couldn’t determine if those in the air pocket tried to escape, but it’s tragic that a piece of equipment that usually saves lives – an inflated life jacket – would have hindered this.
“Life jackets are crucial life-saving devices because they provide buoyancy and certain types can keep you afloat the right way up with your head above water, even when you’re unconscious.
“But sometimes – as in this case – users need to remove an inflated lifejacket while in the water.”
Kozhuppakalam said TAIC was calling for Maritime NZ to include the information in their public education work.
Further, he said, vessel operators need to regularly inspect inflatable lifejackets and provide safety briefings that include instructions on lifejacket deflation and removal.
TAIC said due to the suddenness of the capsize those on board the i-Catcher were unable to retrieve the Emergency Position Indicating Radio Beacon to alert authorities.
“The EPIRB remained secured in its bracket underneath the upturned hull,” the report revealed.
“There is a significant safety benefit for vessels equipped with EPIRBs that are manually released and activated to carry a reliable secondary form of communication suitable for the location and conditions such as a Personal Locator Beacon.
“This practice greatly improves the likelihood of alerting authorities to an emergency should a sudden event occur.”
Kozhuppakalam said boat crews “should carry beacons to improve the chances of rescue when an EPIRB proves inadequate”.
LESSON TWO - LIFE JACKETS
And, the tragedy highlighted the importance of lifejacket awareness.
“Lifejackets are a critical lifesaving appliance. On the day of the accident, the vessel occupants were well equipped, wearing inflatable lifejackets suitable for the vessel’s operation,” investigators said.
“The circumstances of this accident highlight the importance for people to understand how to safely deflate and remove an inflatable lifejacket while in the water, should they need to do so in an emergency.
“Pre-departure safety briefings should include doffing procedures as part of lifejacket operational instruction so that vessel occupants are well informed should a sudden emergency occur.”
TAIC acknowledged there were “challenges in co-ordinating the search and rescue operation resulting in delays and elevating risk to those responding”.
However, it was “unlikely that the delays contributed to the overall outcome of this accident, given the toxic environment within the air pocket of the upturned hull”.
“Nevertheless, valuable lessons can be learned from this response to better prepare for a search and rescue response for similar accidents in the future,” said the report.
TAIC said “all mariners, maritime regulatory agencies, industry stakeholders, recreational boaters, lifejacket manufacturers and their consumers, and agencies and operators involved in search and rescue operations” would benefit from the lessons learned after the tragedy.
LESSON THREE - EMERGENCY SYSTEM
Kozhuppakalam said the report provided “detailed analysis” of another area of concern for the commission – New Zealand’s system for fire, ambulance, police and coastguard emergency responses, with seven recommendations to resolve six major safety issues.
“The commission found delays in the system and restricted information flow. And water rescue procedures should’ve included early engagement of the police dive squad for their expertise, but didn’t,” he explained.
“There were limitations in police’s resources to coordinate deployment of helicopters, boats and other assets during a Category I maritime search and rescue.
“And the Kaikōura region was vulnerable in an emergency because it wasn’t resourced to respond to a large maritime accident and had no maritime rescue plan for the region.
“The commission has issued seven recommendations to resolve the safety issues; it’ll require coordinated work by emergency services, local councils, and central government bodies.
TAIC said it was “important for vessel owners and operators to be familiar with the state of fuel systems onboard their vessels through regular inspections for deficiencies, ensuring the safety of the vessel and its occupants”.
Kozhuppakalam said another “area of concern was ‘regulations and standards”.,
“In New Zealand, the commission is calling on Maritime New Zealand to improve oversight of vessel surveys to detect safety issues like fuel system defects,” he said.
“Lifejacket servicing requirements must be improved to ensure they work correctly. Internationally, standards for lifejacket usability must be clearer, including guidance on deflation and removal.”
TAIC REPORT - POLICE RESPOND
Assistant Commissioner Mike Johnson said police accepted the TAIC findings.
“This was a terrible incident for the community and our thoughts remain with the victims, their families and friends, and the community,” he said.
“Police is continuing work with Rescue Coordination Centre New Zealand (RCCNZ) on the findings of the report.
“Our on-call practices and tasking processes have been streamlined and continue to be improved.
“The joint Maritime Rescue Plan for Tasman has now been prepared and is in the final stages of being signed off.”
Johnson said standard operating procedures had also been updated to include that national dive squad “must be contacted for advice and availability in life-threatening water rescue events”.
“This investigation by TAIC has been important for all of us to learn from,” he said.
“We are putting recommendations in place and looking at where we can support partner agencies across all the recommendations.”
Anna Leask is a Christchurch-based reporter who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 18 years with a particular focus on family and gender-based violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nzHowever
