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The 100-page report by the Traffic Accident Investigation Commission highlights repeated
failure of the safe ship management (SSM) inspection system to identify problems with Kotuku, the boat's poor condition, its carriage of passengers without necessary steps being taken, life-saving equipment that did not work or was missing, the hypothermia-hastening effects of alcohol and the use of cannabis by a working crew member.
The report provides the first conclusions from two investigations into the tragedy that unfolded in Foveaux Strait on May 13, 2006.
Maritime NZ is completing its report, which is expected to follow soon.
Six of nine people aboard Kotuku died when the vessel capsized and sank in the Breaksea Island group while returning to Bluff with catch and equipment from a muttonbirding trip to the Titi Islands.
Three generations of a Bluff family died in New Zealand's worst maritime disaster since the sinking of the interisland ferry Wahine 40 years ago this month.
The sinking claimed the lives of Peter Topi (78), who was at the helm for the trip to Bluff, his daughter, Tania Topi (41), and grandchildren Shain Topi-Tairi and Sailor Trow-Topi (both 9), Clinton Woods (34) and Ian Hayward (52).
Three others - Peter Topi's son, Paul Topi (46), a former skipper of Kotuku, his nephew Dylan Topi (16) and Kotuku owner-skipper John Edminstin (56) - survived after swimming about 500m through heavy seas to Women's Island. Mr Woods reached the island, but died awaiting rescue.
The TAIC report focused on not only fishing industry regulator Maritime NZ, but a range of organisations and individuals, including Bluff-based Mr Edminstin, and inspection companies.
It also criticised a fishing industry culture that viewed maritime legislation with skepticism, although found that was not surprising given the tacit approval by regulators for noncompliance.
The tragedy was a ‘‘sentinel event'' in New Zealand's history and a warning that larger problems must be fixed once and for all, TAIC chief commissioner Bill Jeffries said.
‘‘It is all too clear that the dead, the survivors, and their families were failed by a maritime regulatory system that should not have allowed the Kotuku to be at sea . . . in addition to a number of misjudgments by those responsible for the ship on its fateful voyage,'' Mr Jeffries said.
The investigator in charge of the Kotuku accident, Captain Doug Monks, said the boat would have been able to manage the sea conditions had it been in good condition, had crew been able to clear the decks of water, and if the skipper had been aware of the exact stability of the boat so it could be loaded appropriately.
More people might have survived if the life raft had been better installed and there were the right number of life jackets available and stored in an accessible place.
Mr Jeffries said Maritime NZ and the Maritime Safety Authority before it, and inspection companies and their inspectors, had been ‘‘working with and patching up an unsatisfactory and unevenly applied maritime regulatory system for too long''.
‘‘Meanwhile, commercial pressures and a culture that excused shortcomings appeared to have permeated both the inspection system and the under-24m fishing fleet at the expense of good safety, seamanship, and lives.''
Another accident last year had put Maritime NZ ‘‘on notice'' and the organisation was already working to address the six recommendations laid out in yesterday's report but there was still some way to go he said.
He urged Maritime NZ to make sure everyone involved - inspection companies, owners and Maritime NZ - met their legal responsibilities. He said the commission's job as an overseer of regulatory bodies was not to apportion blame but identify and analyse the factors that contributed to the Kotuku's sinking so that lessons could be learned from it.