Showing posts with label RFI report. Show all posts
Showing posts with label RFI report. Show all posts

Thursday, October 02, 2008

Why no search for the Gaul?

Although the approximate position of the Gaul had been well known, both in official and unofficial circles, in the 23 years that preceded its discovery, successive governments were reluctant to survey the area in question, and to locate and identify the wreck.
It was only in 1997, when TV producer Norman Fenton chartered a vessel and launched a search in the Barents Sea, that the position and identity of the wreck could be confirmed. Finding the wreck took him no longer than six hours. His discovery triggered an obvious question: why had a search for the wreck not been carried out earlier, this would have put an end to much of the speculation and rumours that had surrounded the vessel’s loss and, more importantly, would have helped to ease the grief, frustration and anger felt by the families and friends of those who had perished with the Gaul.
The discovery of the wreck obliged the Government to answer this question; hence, in April 1999, the Deputy Prime Minister, John Prescott, asked Mr Roger Clark, Head of Shipping Policy in the DETR, to conduct an ‘independent’ [1] investigation into why there had been no search for the Gaul after her disappearance in 1974.
Mr Clark applied himself to the task and, a year later, his findings were published in a 60 pages DETR report (see Annex 1).

In brief, the Government’s justification, presented within Mr Clark’s report, claimed that:
Initially we didn’t really know where the vessel was and it would have cost too much to find her and, even if we were to find the vessel, the expense of carrying out an underwater survey of the wreck could not be justified in terms of the benefits it would bring for marine safety.
John Prescott lauded Mr Clark’s conclusions and expressed his total confidence in their soundness and objectivity.

During the 2004 Re-opened Formal Investigation, in response to the victims’ families’ dissatisfaction with Mr Clarke’s explanations, justice David Steel, the Wreck Commissioner, re-examined the arguments, then endorsed, in his turn, Mr Clarke’s earlier conclusions (see the final report of the RFI [2]).

While the official reasoning may appear quite plausible, we have reasons to believe that, in fact, the Government had never been too keen to discover the location of the wreck, not on the grounds advocated by Roger Clarke, but for an entirely different reason: i.e. because a survey of the wreck and an analysis of the evidence that it revealed would have raised questions as to the adequacy of her design. The DfT’s marine experts, it now appears, had long suspected that the arrangement of the duff and offal chutes on the Gaul were a weakness in her design and that this weakness might have been a causal factor in her loss.

(Further details to follow)

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[1] As head of the DfT’s shipping policy section, Roger Clarke could hardly be considered independent of the government whose actions he was asked to investigate

[2] “We accept the Department’s submission that its actions were solely directed to balancing the interests of those immediately affected by the loss of the GAUL with the wider public interest and the resources available

Tuesday, July 22, 2008

Answers in a fishtail

In our previous posts (27 April, 05 May and 12 June), we have discussed the matter of the inner covers to the offal chute on the Gaul and provided photographic evidence from the wreck which showed that these covers had in fact been secured in the closed position prior to the loss of the vessel and that they could have been opened by the forces of the sea before sinking took place.

The 2004 RFI panel thought, however, that the offal chute inner covers – found open on the wreck – had been negligently left so by the crew. (The same explanation was employed in respect of the duff chute inner covers, which had also been found open.) (See also this POST)

It must be mentioned here that the regime on the Gaul was such that the operation of offal chute would have fallen under the jurisdiction of the factory manager and his team, while the operation of the duff chute was under the control of the deck crew.
This arrangement gave the RFI experts the opportunity to claim that the factory deck staff, as non-fishermen, had been ignorant about the importance of keeping the offal chute inner covers closed when not in use and, tragically, had failed to secure them at the end of a busy working day.

Unfortunately, the RFI also failed to draw any conclusions from the relevant information that was available to the inquiry. This information relates to the following facts:

1. The offal chute overboard discharge acted as a relief valve during the fish processing operations and, as such, it would only be used when the fish meal plant (rate = 25 tonnes/day) was operating at full capacity or when the fish meal hold was full (capacity = 120 tonnes)
It is also known that the Gaul skipper’s reports recorded that at the time of the loss, the vessel had only managed to accumulate about 20 tonnes of fish fillets onboard together with about 7 tonnes of fish-meal (i.e. a poor catch for the period she was fishing).
The logical conclusion that follows from these data is that there would have been no need for the factory crew to use the offal chute overboard discharge during the vessel’s last voyage.

2. Furthermore two witnesses (Messrs George Petty and Raymond Smith) testified at the hearings that the offal chute would not have been used during the last two voyages in the Gaul’s short life, simply because the fish meal hold was never filled.

More explanations, quotes and details on the subject have been published at this LINK and HERE (diagram).

Like the rest of the conclusions in the 2004 RFI report, the assumption of negligence by all parts of the crew, no matter how implausible, were forced into relevance and given the status of fact.

Monday, May 05, 2008

Continuation from previous post

The damage to the forked lug (securing clip) of the offal chute lid, which is visible in the image below, indicates that the crew of the Gaul (prior to the loss of the vessel) had secured the inner covers in the closed position. The covers were subsequently damaged when the sea burst them open.

In the above detail, the normal outline of the forked securing clip was drawn in orange

This evidence clearly negates three of the principal conclusions of the RFI:
1. That proper use of the inner covers would have prevented water ingress
This is incorrect - the above photo indicates that the covers had been used ‘properly’ but, unfortunately, this could not prevent the water ingress.
2. That, at the time of the loss, the inner covers were not closed and secured
This is incorrect – the evidence indicates that not only had the covers been closed and secured at the time of the loss, but also that the forces of the sea subsequently opened them.
3. That, at the time of the loss, there was no physical reason to prevent the crew from closing and securing these covers
The photo shows clearly that the securing arrangements were physically damaged and as such could not be used to secure the covers. It is most likely that this damage occurred ‘at the time of the loss’
Besides, the inner covers were in no way strong enough to be watertight. If they had been, they would not have been damaged.

More to come...

Monday, March 24, 2008

Clues and toggles

In continuation of our post of March 09, we are now publishing a DOCUMENT, which points to some differences and similarities in the ways in which the re-opened formal investigations (RFIs) into two major marine accidents: the MV Derbyshire and FV Gaul have been conducted and the reasons why the first was able to deliver better quality results than the second.
We considered the formal investigation into the loss of the MV Derbyshire, in which, initially, the Assessors wrongly concluded - on the basis of a rope seen emerging from the Bosun’s store hatch opening and of a simple examination of the disposition of that hatch’s toggles - that the loss of the vessel had been due to crew error.
In a curiously similar manner, the Gaul RFI also put the blame for the loss of the trawler on the crew, who, the RFI panel claimed, had neglected to close the inner covers to two openings in the hull - this time on the basis of a ligature apparently holding the vessel’s duff chute inner lid in the open position.
However, as the Derbyshire Assessors’ report had been made public two years prior to the RFI court hearings, their findings were openly examined and contested when appropriate and this allowed the court to arrive, in the end, at a set of different and more robust conclusions.
What is worthy of note here is that, in the Derbyshire RFI, it was the subsequent examination by independent experts of the condition and position of the Bosun’s hatch cover’s toggles that led to the rebuttal of the Assessors’ initial verdict of crew error.
Finally, the court concluded that the crew had not failed to secure the hatch lid and that the rope emerging from the Bosun’s store hatch opening was nothing more than post-casualty debris.
Unfortunately, despite the precedent provided by the Derbyshire inquiry, during the Gaul inquiry no external, independent examination of the case was allowed.
In the Gaul Investigation, the report of the Assessors, the retained experts and the court was presented at the end of the RFI as one final document, ‘set in stone’. Nonetheless, a mere glance at the position of the toggles, as shown by the underwater survey footage, suggests that the inner lids of both chutes on the Gaul had been initially closed.
Surprisingly, during the court hearings, neither the strongback bar (which, in conjunction with two toggles, secured the offal chute cover) nor the condition of the toggles was even mentioned.
In addition to and more intriguingly than this oversight is, however, the creative, ‘non-figurative’ manner in which the retained experts produced the drawings of the duff and offal chutes, in their supposedly as found’ condition.
The toggles, which in the underwater survey video footage are clearly shown to be in the ‘hatch closed’ position, appear on the experts’ drawings to be in the ‘hatch open’ position.



The unfortunate effect of these inaccuracies is that it can mislead subsequent examiners into concluding that, since all the toggles were found in the ‘open’ position on the wreck, the court’s finding that the crew had left the hatches open prior to the loss of the vessel is most likely correct.

More about it HERE

Sunday, March 16, 2008

Health and knowledge

Since we started this blog and the related Gaul website, almost two years ago, none of the experts in the 2004 RFI have deigned to comment or, in any way, express agreement or discontent with the technical propositions enunciated on these sites.
When a professional finds his opinions challenged or publicly criticised by his peers, he is normally prompted to reply either by defending his theories or by amending them. The experts in the Gaul RFI, by contrast, have buried themselves in silence, and although we have repeatedly tried to engage with them, they never replied. Don’t you find this odd?
The government didn’t even process the RFI recommendations, as customary after each major investigation, not as much because they were irrelevant, but for fear that the gilding will come off its findings at the slightest touch.

In contemporary Britain, it appears, truth is nothing more than an empty shell that can be filled with whatever meaning suits the government’s interests of the moment.
Strange events are left un-investigated, important questions are blithely ignored and, like the profane who must be prevented from defiling sacred knowledge, we are being taught to content ourselves with secrecy, half truths and disinformation.
It is best not to argue, the cynics recommend, because letting the humbug stuff you full of prunes is nowadays less harmful to your health than properly checking the facts.

Saturday, March 01, 2008

Wilful Ignorance

When they’ve finished filling in their various questionnaires, the Fraud Squad detectives set about catching criminals.
But, how do they perform this task? Do they go out into the street, copping people at random? No, of course not! They employ logic.
The unfortunate thing, however, is that their logic can sometimes take the shape of the politicised Heads of the Met.
In our previous posts we reported on the progress made by the Fraud Squad in response to our fraud complaint. Today, we are able to provide you with an exciting update:
After 11 months of rumination, the Met detectives were finally able to shout Eureka, as they found an answer to our concerns, and a simple one at that.
In a letter signed by a Detective Chief Inspector of the Fraud Squad, we were informed that the design fault on the Gaul - which, we contended, could have competed as a more likely cause for the loss of the vessel than crew negligence, had evidence of this fault not been withheld – was, in fact, recognised by the 2004 RFI and duly mentioned in the final report, at paras 2.44 –2.49.
How extraordinary! The naval architect, who has been carping about the final report to the RFI and its findings for more than two years now, never realised that the Investigation Panel had in fact agreed with him.
How could he have missed the meaning of those six vital paragraphs, which the Met detectives’ perspicacity identified as proof that the RFI panel didn’t keep shtum about the design fault in question?
Well, the truth of the matter is that the above-mentioned paragraphs[1] refer, in fact, only to:
  1. a calculation error in the design of the chutes, the unfortunate significance of which being, nevertheless, overlooked (see DESIGN ERROR 2 document);

  2. a mention of the fact that the vessel owners had annotated the drawing of the chute with the statement “the design of the watertight hopper hatch cover was “too fiddly” " – statement endorsed by the final report despite being factually incorrect;

  3. the unrealistic notion that the one inch square section of the steel hinge spindles would have become rounded with normal use (while, in the same paragraph, the experts advise that they had visited the Gaul’s 29 year old sister vessel on which, the same type of spindle had not, even by that time, become rounded);

  4. a suggestion that the design of the hinges would have “inevitably resulted in corrosion within the brass gland” - in fact the ‘brass gland’ referred to therein was a sintered bronze, self lubricating, bearing, and

  5. a statement that the flaps could not be maintained without destroying them, which, as we explained HERE as well as in this POST and on page 22 of the TECHNICAL REPORT, was pure misconception.

Nowhere in the report is it mentioned that the non-return flaps opened the wrong way round (a major DESIGN FAULT) and, therefore, would have failed to act as the principal strength barrier against seawater flooding, as they were supposed to. And that is the crux of the matter. Plain as daylight.

To claim otherwise is brazenly insincere, similar to saying that white is black and black is white.

When questioned about these inadvertences, the DCI professed ignorance of the details of the case, passing the buck to the lowest rank: i.e. a constable in his squad.

(To be continued)
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[1] A copy of paras 2.44 –2.49 is provided at THIS LINK

Monday, August 20, 2007

Brief statement

Mr Tony Bowman - Managing Director of TMC (Marine Consultants) Ltd was the technical expert appointed by the Attorney General to ensure that all relevant technical evidence was presented to 2004 Re-opened Formal Investigation (RFI) and to provide expert advice on the matters related to the loss of the Gaul.
Today I called Mr Bowman and asked for his opinion on the evidence related to the design defect in the duff and offal chutes on the vessel - evidence that had been produced by the MCA and available to those concerned since 2002.
The TMC Director would offer no comment on the matter other than stating that all he had to say about the design of the Gaul’s chutes was contained in the transcripts of evidence and RFI final report.
Well, we’ve had a good look at those documents already…

Sunday, January 14, 2007

The third round of Parliamentary Questions and Answers - part 2

‘Attention to detail’

The fourth parliamentary question that was addressed to the Secretary of State for Transport concerned the mode and date of implementation of the four safety recommendations arising from the F. V. Gaul Re-opened Formal Investigation.
The Minister’s latest response to this question was very eloquent and reassuring, but, alas, it was also factually incorrect and misleading. The four formal safety recommendations from the RFI have not as yet been implemented and, had it not been for this recent enquiry, it is unlikely that they would have ever been tackled.
One of the principle faults with the Minister’s response, however, is the fact that he seemed to have opened the RFI Report at the wrong page… (!!) that is, he has copied and responded to text from page 280 of the Report, which does not in fact contain the four formal safety recommendations - these are actually detailed on pages 286 and 287 of the formal document.
To assist matters we have reproduced the four safety recommendations together with our further comments on the Minister’s response at this LINK.

Monday, October 02, 2006

Improbable impossibility

An extract from the Report of the Re-opened Formal Investigation into the loss of the FV Gaul:

"21.1 What was or were the probable cause or causes of the loss of the GAUL?
A sudden and rapid accumulation of water on the factory deck, (...)
21.2 What possible causes can be eliminated by the evidence which is now available?
All other causes including, seizure, scuttling, fire, collision, explosion, missile attack, torpedo attack, striking a mine, icing, cargo shift,structural failure, grounding, snagging a seabed cable or a submarine.
21.3 What other possible causes remain open?
None."

By definition, probable is something likely to happen but not certain. What is not absolutely certain leaves room for other possibilities. Therefore other possibilities (i.e."all other causes") cannot be eliminated.
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"There is no use in trying," said Alice; "one can't believe impossible things.""I dare say you haven't much practice," said the Queen. "When I was your age, I always did it for half an hour a day. Why, sometimes I've believed as many as six impossible things before breakfast." (Excerpt from "Alice in Wonderland")
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Sunday, September 17, 2006

"18.17... it is now necessary to focus on the important and central feature of the vessel in this case, the duff and offal chutes. In this connection, it is important to note that although both chutes were found on the wreck to be open both in way of the non-return flap and the internal top cover, there is no known mechanical reason why this was so." (Report of the Re-opened Formal Investigation into the Loss of the FV Gaul)

(!)

Thursday, August 31, 2006

Critical comments on the findings of the Re-Opened Formal Investigation (RFI) into the loss of the trawler Gaul


Following a careful study of the report into the loss of the trawler Gaul published in December 2004, at the end of the RFI, (http://www.fv-gaul.org.uk/), a number of questions and objections as to its content and conclusions arise.
In essence, the inquiry concluded that human error on the part of the crew, shore maintenance staff and the vessel's owners was the cause of the vessel's loss.
In this post, it is suggested that what actually led to loss of the vessel was a design fault in the construction and arrangements of the duff and offal chute openings and their means of closure.
The RFI conclusions in brief
  1. That the Gaul capsized and sank in severe weather following undetected seawater ingress into the factory space. The water entered this space through two hull side chute openings[1].
  2. That each of these two hull side chute openings had two means of closure: an outer non-return flap valve and a hinged inner cover; and that both of these closures were open prior to, and during the loss of the vessel.
  3. That, as a result of inadequate shore-side maintenance, both outer flap valves had become seized in the open position due to corrosion in their hinges, and that they had been in this condition since the time of the vessel’s departure from Hull, 16 days prior to the accident;
  4. That the hinged inner covers had been left open and unsecured by the crew; and
  5. That, had the crew closed the inner covers, this would have been sufficient to prevent the loss of the vessel.
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[1] These chutes facilitated the overboard discharge of duff and offal waste resulting from fish processing operations within the factory space.
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The design fault
The duff and offal chute openings in the hull of the vessel were provided with a two-barrier closure system: an outer non-return flap (the strength barrier) and an inner cover (the leakage barrier), and these were both required to be closed in order to maintain the hull’s full watertight integrity.
Unfortunately, it can be demonstrated that the outer non-return flap arrangement, which was present onboard the Gaul was such that, in certain circumstances, the sea could act directly on the exposed free edge of this outer flap and push it open.
In such circumstancess, if the inner covers had also been open or had subsequently failed[2] , the seawater would have been able to enter the vessel unhindered.
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[2] It should be mentioned here that the inner covers were neither designed nor intended to withstand, on their own, the forces of the sea
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For a pictorial explanation of the design defect on the Gaul, please follow this link.
This shows that a slightly different design arrangement of the outer non-return flaps would have prevented the rapid flooding of the Gaul, even with the inner covers left fully open.
Possible causes for the loss of the Gaul
The Re-opened Formal Investigation came to the conclusion that the outer non-return flaps in the duff and offal chutes on the Gaul had been seized in the open position since the time of the vessel’s departure from port - this conclusion having been drawn from the fact that the flaps were found to be in the open position during the 2002 underwater survey.
The fact that the inner covers were also found to be open during this survey was ascribed to the crew’s failure to close them.
In his closing remarks the judge stated firmly that "no other possible causes remained open".
The document published HERE shows that not only was this incorrect but that there are other more plausible explanations for the loss of the vessel:
Other aspects and questions
Linked to the above issues, there are also a number of elements within the formal report which appear incorrect:

1. When defining the scope of ship classification, the formal report failed to include the Classification Societies’ responsibility for watertight integrity. The definition within the report reads:
Class/classification = covers the development and worldwide implementation of published rules and regulations which will provide for: 1. The structural strength and scantlings of all essential parts of the hull and its appendages; ......”
While the definition as per IACS – Quality management System requirements manual states in respect of “Classification service” point 1. that “The structural strength (and where necessary the watertight integrity of) all essential parts of the exterior boundaries of the ship or offshore installation and its appendages.”
Why was the alteration of this international definition necessary in the formal report?
2. The definitions provided in the formal report for weathertight and watertight properties read as follows:
Watertight – impervious to the passage of water, as applied to ship’s structure, closures and joints. A watertight opening is so constructed that when closed, it will prevent water under pressure from passing through, and normally incorporates a gasket.”
Weathertight – capable of being sealed to exclude water in normal sea conditions. A weathertight opening is typically designed to keep out rain and spray only.”

Whereas watertight and weathertight are terms that have agreed International definitions such that items which are categorised and accepted as watertight or weathertight need to meet strict requirements for construction, strength, material thickness, gasketing, hinges and securing clips (these are generally set by National or International standard).
Watertight means capable of preventing the passage of water through the structure in either direction with a proper margin of resistance under the pressure due to the maximum head of water, which it might have to sustain.”Weathertight means that in any sea conditions water will not penetrate into the ship.”
(SOLAS 1974 as amended, 1966 Load Line Convention and Torremolinos Convention 1977)
Why were the definitions for watertight and weathertight used in the report incorrect?

Thus, a weathertight fitting should be designed to withstand, in any sea conditions, water pressure and prevent the passage of water from one side only.
A watertight fitting, on the other hand, must, when closed, prevent the passage of water through an opening no matter which side is under pressure.
Since the adequacy and functioning of the ship’s duff and offal chute fittings was central to the investigation, has not their confusing definition been a serious failing?
Why have the inner covers of the Gaul’s duff and offal chutes been categorised throughout the report as being of a ‘watertight’ standard, whilst, in reality, the construction, strength and arrangement of these inner covers would not even meet the requirements that would be expected for ‘weathertight’ closures?
Watertight and weathertight fittings generally make use of rubber gaskets and clips (or bolts) to seal steel-to-steel joints and prevent the passage of water. Watertight fittings need many more bolts/clips than weathertight fittings.
The principle shortfall in the strength of the chute’s inner covers is related to their direction of opening when considered in conjunction with external sea pressure loading (full sea loading on the covers would only be resisted by 3 butterfly nuts, instead of the overlapped gasketed steel plating arrangement that is normally associated with a weathertight joint).

3. It is also stated in the report that: “it is not clear how the spindle could have been repaired or replaced should the need arise without burning off the balance weight from the connecting arms”However, the construction drawings for the duff and offal chutes show quite clearly that the hinge, spindle, balance weight and connecting arms can be readily dismantled for maintenance, repairs or replacements. (?!)
4. Is it not the case that, if the inquiry had found that the Gaul had sunk due to a design defect, the victims’ families would have been entitled to compensation?
Extract from The Merchant Shipping (Convention on Limitation of Liability for Maritime Claims) (Amendment) Order 1998:
" 1. The limits of liability for claims other than those mentioned in Article 7, arising on any distinct occasion, shall be calculated as follows:
(a) in respect of claims for loss of life or personal injury,
(i) 2 million Units of Account for a ship with a tonnage not exceeding 2,000 tons,”


This would amount today to approx. 3m USD per life lost (1 SDR = 1.48727 USD)
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For those who wish to read the full technical argument behind the above points, please visit this link