The 'probable cause' of the sinking of the fishing vessel 'Louisa' was flooding of the hold.
Lifejackets used by the crew were faulty, and had the emergency services not been unnecessarily delayed, there could have been more survivors.
The Marine Accident Investigation Branch has just published the findings of its investigation into the sinking off Mingulay in April of 2016.
Three men were lost in the tragedy - the bodies of Martin Johnstone, 29, from Halkirk, Caithness, and Chris Morrison, 27, from Leverburgh, in Harris, were found shortly after the boat sank.
Fellow crew member and skipper, Paul Alliston, 42, from Lochs, Lewis, remains missing despite several major land and sea searches.
Fourth crew member, fisherman Lachlan Armstrong, 28, from Stornoway, swam to shore and clung to rocks before being rescued by lifeboat.
The report states: “The skipper and crew were all tired and had gone to bed in the accommodation, and the hold bilge alarm failed to wake them because the alarm sounder in the crew cabin had previously been disabled.
“When abandoning the vessel, the crew attempted to launch the liferaft. However, the liferaft failed to inflate because its CO2 cylinder was empty, which resulted in the skipper and crew having to enter the water. Although they had all donned lifejackets, the skipper and two crew became unresponsive through cold water immersion and were later found face down in the water by the rescue services.
“Before abandoning Louisa, the crew activated the vessel’s EPIRB. Although UKMCC had received an initial alert by 0239, the first request for a SAR asset was not made by HMCG until 0322.
“Had the rescue services arrived on scene earlier, it is possible that there would have been more survivors.”
The report highlighted several safety issues.
The circumstances of this accident and subsequent trials and testing undertaken following the accident have raised concerns about the effectiveness of the lifejackets worn by Louisa’s skipper and crew
The condition in which the vessel was left while all on board went to bed in the accommodation was inconsistent with best practice and demonstrated an underestimation of the risks associated with flooding and foundering
The hold bilge alarm sounder in the crew cabin had previously been disabled to prevent routine disturbance. Consequently, the skipper and crew did not receive any early warning that the hold was flooding
Significant items of the vessel’s lifesaving appliances, including its liferaft, were out of date for service or replacement
The liferaft’s CO2 inflation cylinder had not been refilled during scheduled maintenance owing to deficiencies in the liferaft servicing work process
Weaknesses in knowledge and procedures led to delays in the SAR operation
Recommendations have been made to:
The Maritime and Coastguard Agency to conduct urgent research into the suitability of lifejacket testing protocols and to enhance its response to satellite distress beacon alerts.
Premium Liferaft Services and Thameside Fire Protection Company (2017/133) to improve their servicing procedures with the aim of readily identifying anomalies in recorded CO2 inflation cylinder weights.
The vessel’s owners to develop a planned maintenance system to ensure safety equipment is adequately maintained, and to conduct formal risk assessments to match a vessel’s full range of anticipated activities.
A spokesman for Louisa fishing vessel owners, Duncan and Murdo Kennedy, said: "The tragic events of 9 April 2016 resulted in the loss of three fine fisherman and our thoughts remain with the families of Martin Johnstone, Chris Morrison, Paul Alliston and surviving crew member, Lachlan Armstrong.
"We have fully cooperated with the MAIB inquiry and are committed to implementing the report's recommendations. We hope the wider issues raised in the report will lead to improved safety for all those working at sea and prevent any similar incident from happening."
The full report can be viewed online here.