Have a read very interesting below are the recommendations 

25Feb19_Imedi_Incident_Report.pdf

Introduction: Following the loss of Jon Santarelli during the 110th running of the Race to Mackinac in July 2018, the Chicago Yacht Club appointed a Committee with a broad range of experience to review the incident in order to make recommendations regarding the lessons that may be learned from it. The objective of this inquiry is to reduce the chance of similar accidents by thoroughly reviewing the events and examining the use of safety equipment. The recommendations following this review have been developed by the Committee based on its assessment of the events and are designed to enhance safety in the sport. The Committee notes there was some variation in the crew’s recollection of events likely due to their varying positions and activities at the time. The Committee wishes to thank the Chicago Yacht Club for its support in implementing the review and also to thank those who provided the information on which this report is based, including eleven of the Imedi crew who offered both written reports and interviews describing their impressions of what happened. In addition, the Club wishes to thank all members of the Committee for their time, effort, and dedication in undertaking this vital task for the sailing community. The Committee’s detailed report follows. Brief overview: Essential elements of the incident. All times are Central Daylight Time. On July 21, 2018, at approximately 14:26 CDT, Jon Santarelli, slipped overboard from the cockpit of the TP 52, Imedi, as she sailed northeast from the 14:00 start of the Race to Mackinac. The Imedi crew immediately tacked and circled back to Jon’s position in the water, never losing visual track of him, but were unable to stop the boat close enough to retrieve Jon, due to the 20-25 knot winds and 6-8’ seas. They circled again and came closer to Jon on the second attempt, this time with the engine running, but just as they got close to Jon, a wave forced the boat up and over Jon and he went under the boat from starboard to port. Imedi circled a third time, and this time they were able to stop the boat very close to Jon, but as they tossed Jon a line and he raised his arms, he sank below the water and was not seen again. His life jacket, which was reported as set for automatic inflation, never inflated and he was never seen to try to manually inflate it. In the subsequent search, Imedi was joined by the Coast Guard, CFD, CPD, three helicopters, several other power boats and eight Race to Mackinac entrants who had stopped racing to help search. The search was called off at 4 dark, after five hours with no results. A week later, on July 28th, Jon’s body was found floating 4 nautical miles east of the Chicago Harbor Entrance. Chicago Yacht Club assembled a Committee of local and national sailors to review the incident, in an attempt to understand it and make offshore racing safer. This report is a result of that Committee’s efforts. The report begins by setting forth the background with respect to the race, the weather conditions, the boat, and the crew, followed by a detailed description of what occurred. It concludes with recommendations regarding the lessons learned from the incident. The appendices include more details and supporting information. Lessons to be Learned: As a result of the Committee’s investigation, it became clear that there are lessons to be learned from this incident with respect to malfunctioning personal safety gear, use of additional safety equipment on board, and vessel control under challenging conditions. Safety Issues to be examined in this report include: 1. Command structure effecting clear and timely communications during an onboard crisis 2. Safety gear functionality and crew understanding of its use 3. COB recovery routines practiced for specific vessel and expected conditions 4. Adequate training for effective response by a person in the water.

Recommendations: The Committee makes the following recommendations, based on its review of the Imedi events: I. Understand the importance of a comprehensive dock-talk before departure, to include: a. Define the command structure: who is in charge, 2nd in charge. b. Define procedures and each crew member’s role in COB as well as other emergency scenarios. (see Station Bill: Appendix D) c. Understand electronic DSC and COB signals and how to operate them quickly. d. Have stated rules for when to wear life jackets and use tethers. e. Review safety equipment location map, noting any recent changes. (See Appendix D) II. Highlight the importance of following established COB procedures, including: a. Initial COB “spotter” is the only crew member assigned this duty during the maneuver, freeing others for equally important roles. b. Simultaneously with COB identification, immediately deploy Man-Overboard-Module (MOM) and enter COB location into GPS. c. Broadcast COB event and location, activate DSC button, and continue appropriate emergency communications on VHF 16 until emergency is resolved. d. Establish vessel control for safe maneuvering, which may require reducing sail area. e. Deploy Lifesling as soon as possible and practically prudent. f. Deploy as much additional flotation, including other, non-standard rescue items (e.g. fenders) as practically prudent so as not to impede boat handling. III. Inspect all safety gear and ensure individuals know how to use it: a. Fit and review functioning of life jackets, tethers, AIS personal beacons, etc. b. Insure all COB gear is functional, (e.g. Lifesling, throw rope, MOM, boat hook). c. Train crew on the importance of immediate COB gear deployment to provide additional flotation to the COB and visibly mark the location for the crew. d. Insure COB gear is positioned to allow safe access within 5 seconds of COB. IV. Practice for COB situations specific to the boat and expected conditions: a. Insure clear, timely commands from one source to avoid confusion. b. Establish control of the boat and ability to hold position before attempting recovery. c. Know which recovery procedures are best for your boat in the current conditions. d. Know that the boat itself can become a dangerous factor adding significant risk to any COB recovery attempt. Have a practiced plan for reboarding the COB, e.g. Lifesling or 19 long halyard with harnessed crew, to minimize the time in close proximity to the COB and allow the COB to be hoisted aboard quickly. For some vessels, using a “swimmer of the watch” may be prudent to minimize the potential danger of proximity to the COB. This option has been successful on professionally-crewed boats, which maintain a boat length distance from the COB, send a rescue swimmer on a spooled retrieval line to tether to the COB, and then have the crew winch them both back and onboard with a halyard snapped to the retrieval line. A rescue swimmer is typically only used on professionally-crewed boats and should only be considered if the swimmer is fully trained and qualified to perform that function and has extensively practiced on that boat with that crew. e. In the absence of the ability or willingness to deploy a rescue swimmer, the Lifesling can serve a similar end by connecting the COB to the boat without bringing the boat alongside the COB. Once the COB is in the Lifesling, a halyard can be used to quickly hoist them aboard so that the COB spends minimal time adjacent to the boat, thus minimizing potential injury from the boat. V. As a person in the water, take immediate measures to manually activate any safety equipment, including if necessary manual backup systems for inflatable life jackets. VI. Enhanced Training is warranted regarding the maintenance and use of inflatable life jackets: a. Numerous incidents have been reported from multiple sources regarding failure of automatic inflation systems arising from not being familiar with manufacturer’s recommendations for inspection, maintenance and operation procedures. b. Steps should be taken to raise awareness to the importance of proper inspection, maintenance, and replacement of inflatable life jackets. c. Those wearing inflatable life jackets should be fully familiar with and be ready to utilize the manual backup systems for automatic inflation, including the manual pull inflator and oral inflator. d. Boat-supplied life jackets should be assigned to and fitted to specific crew members