Department of the Environment, Transport and the Regions

Press Notices

Press Notice 246: MAIB Samphire of Wells report published - 29 March 2000

The Marine Accident Investigation Branch (MAIB) has today published its report on the foundering of the 4.26m (14ft) dinghy Samphire of Wells on the North Norfolk Coast with the loss of two lives on16 December 1999.
Synopsis
Shortly after 1730 on 16 December 1999 the Maritime Rescue Co-ordination Centre (MRCC) Yarmouth informed the MAIB that a dinghy with two people on board was overdue on a passage from Burnham Overy Staithe to Wells-next-the-Sea. Later that evening the MAIB was informed that one body had been located. An investigation was initiated the next day and was conducted by the Chief Inspector of Marine Accidents, Rear Admiral John Lang.
At approximately 1130 on 16 December 1999, two men manning an open 4.26m (14ft) dinghy, Samphire of Wells, left Burnham Overy Staithe on the north Norfolk coast for the six and a half mile passage to Wells harbour. The weather was fine, sunny, with a light to moderate westerly breeze and high water neaps were predicted shortly before noon. The object of the passage was to take the dinghy to Wells to do some work on it and lay it up for the winter. It had spent the previous few weeks in Burnham Overy harbour.
The dinghy never arrived at Wells. During the early afternoon the partner of one of the occupants became concerned when it didn't appear, and raised the alarm. A search and rescue operation was initiated and at 1850 the Wells RNLI all-weather lifeboat (ALB) found the body of one of the two men floating upright in a pool among shoal water to the west of the Wells harbour channel. He was wearing a fully inflated lifejacket. When eventually landed, he was seen by a doctor and declared dead on arrival.
The second man was found dead six days later in the sea some seven miles to the north of Cromer. He too was wearing a fully inflated lifejacket.
There were no witnesses to the accident. Although one or two pieces of wreckage were found and were thought to have come from the missing dinghy, this could not be proved beyond doubt. Neither the dinghy, nor its remains, have ever been found.
The precise cause of the loss cannot be determined with accuracy. The investigation concludes that the dinghy most probably foundered while making the short open sea passage between Burnham Overy harbour and the entrance to Wells harbour.
The report makes recommendations to improve the chances of survival for occupants of small boats who find themselves thrown into the water.
Conclusions
Findings
(i) There was no overwhelming reason why it was necessary to transport Samphire of Wells by sea. Road transport was available and practical.
(ii) Samphire of Wells was suitable for use in sheltered waters but was vulnerable to being swamped in rough conditions such as might be experienced when crossing a bar or coasting after bad weather.
(iii) The weather on the day of the accident was good with a westerly force 2-3 blowing. On the preceding day a strong breeze to gale force northerly, and therefore onshore, wind had been blowing.
(iv) Both the occupants had sufficient knowledge to handle small craft competently but it is thought that specific knowledge of handling an open dinghy at sea with an inboard engine was less well established.
(v) The dinghy was believed to have been equipped with oars and an anchor but there is no evidence to indicate that flares or any form of radio were carried on the 16 December. It is probable a bailer was onboard and it is thought the electric bilge pump would have functioned.
(vi) The wreck, or hull, of the dinghy has never been found and has not, therefore, been examined, but it is probable that it shipped water before capsizing.
(vii) Both men were regarded as being careful and conscientious. Mr Cracknell had a reputation for being someone who did not take unnecessary risks.
(viii) Samphire of Wells sailed from Burnham Overy Staithe at about 1130 on 16 December and was, quite possibly, last seen to the east of the harbour entrance and heading eastwards.
(ix) A bar lies across the entrance channel to Burnham Overy harbour. Sailing directions, and those familiar with the harbour, advise against crossing the bar if there is any northing in the wind.
(x) There was breaking water at the Burnham Overy Harbour bar when Samphire of Wells crossed it.
(xi) 'White water' was observed along the shoreline at about 1150 on 16 December.
(xii) Both men were able to inflate their lifejackets either before, or very shortly after, being immersed in the sea. They would have found swimming very difficult with the clothing and footwear being worn.
(xiii) Neither man had any suitable means to attract attention to their predicament once they were in the water.
(xiv) Both men would have been subjected to the effects of cold water and would have found it difficult not to swallow seawater.
(xv) There was nothing on either of the two lifejackets to prevent them riding up over the heads of the victims or to prevent water splashing over their faces.
(xvi) Both men died from drowning.
(xvii) The alarm was raised once it was realised the dinghy was overdue and that initial inquiries had failed to identify her whereabouts.
(xviii) Once the alarm had been raised there was no delay in mounting a search and rescue operation.
(xix) The body of Mr Cracknell was located afloat among shoal water to the west of the Wells harbour channel about seven hours after the dinghy sailed. Mr Fortescue's body was discovered six days later floating in the open sea, north of Cromer.
(xx) Both bodies were being kept afloat by fully inflated lifejackets. Had the lifejackets not been worn, there must be doubt about whether they would have been found so easily. The reflective tape on Mr Cracknell's lifejacket greatly assisted the Wells RNLI all weather lifeboat's ability to find it at night.
Causes
Primary cause
Because there were no survivors, physical evidence, or witnesses to this tragic accident, it is not possible to state with certainty what caused it. The investigation concludes, however, that the most likely cause was that she foundered in breaking waves at some stage while on passage between Burnham Overy and Wells-next-the-Sea harbours.
Underlying causes of the accident
(i) The decision to take Samphire of Wells around to Wells harbour by sea and not by road.
(ii) The unsuitability of Samphire of Wells to weather broken water in the open sea. Even if partially swamped she would have been vulnerable to capsize.
(iii) The dinghy occupants' lack of awareness of the sea state likely to be encountered during the passage.
(iv) The possibility that the engine failed while on passage.
Underlying reasons why neither of the occupants of the dinghy survived
(i) Lack of any inbuilt buoyancy in the dinghy.
(ii) The difficulties both victims would have found swimming in the clothing and footwear being worn.
(iii) Inability to preserve body heat once immersed in cold water.
(iv) Lack of any means to prevent breaking water covering the victims' faces.
(v) Lack of any means to prevent lifejackets from riding up over victims' heads.
(vi) Inability to attract anyone's attention once they were in the water.
Recommendations
The RNLI Sea Safety Liaison Working Group is recommended to:
1. Review its existing advice on the preservation of life for anybody finding themselves inadvertently in the water. Such a review should look at all small craft users including those who only go afloat occasionally. It should cover:

• suitable clothing for the anticipated conditions;
• preserving body heat;
• the importance of having the most suitable lifesaving jackets for the intended activity;
• ensuring lifejackets are properly fitted and secured;
• effective means of attracting attention by a survivor in the water;
• informing a responsible and knowledgeable person or coastguard of intentions, including the ETA, prior to departure and reporting the safe arrival on completion.

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