Calypso 2. The survey found eight deficiencies.
Safety management was not one of them.
Calypso 2 was a small commercial vessel operating in Anguilla.
On 11 March 2023, it entered a coastal cove with six people on board.
Large ground seas had developed near the coast.
The vessel turned beam-on to the breaking waves.
It was swamped.
Everyone was washed overboard. Two people died.
The obvious explanation sits on the surface.
The decision to enter the cove was ill conceived.
There was no specific plan. The danger had not been properly considered.
Nobody was wearing a personal flotation device.
But the voyage had already been postponed once because of adverse weather.
The warning remained valid until 12 March. It described dangerous surf exceeding 3m on some coasts and urged people to stay away from rocky coastal structures.
The risk was available to be seen.
The operator had not defined maximum operating weather conditions.
It did not require operational risk assessment or passage planning.
MAIB found no evidence of an equivalent SMS covering the operator’s domestically trading vessels.
Five generic procedural documents were submitted during the investigation.
They were dated 13 March 2023. Two days after the accident.
There was no indication they had existed before it.
Now return to the inspection.
Eight deficiencies had been recorded in August 2022. Drills were not frequent or logged. The primary VHF was inoperative. Charts required updating.
Those were visible defects.
The missing management controls were different.
No safety management deficiencies were raised during either surveyor assessment.
Calypso 2 also had no AIS transponder. The surveyor recorded no observation or deficiency for that omission.
An inspection can identify broken equipment and expired charts while missing the operating logic that decides whether a voyage should proceed at all.
That is the assurance gap.
A certificate or completed inspection cannot make an unsafe operating decision less likely unless somebody critically tests the system behind that decision.
For a DPA or maritime administration, the practical test is not whether procedures can be produced.
Ask what existed before the vessel sailed.
Who defined the weather limit?
Who reviewed the passage plan?
What evidence showed that the controls were used?
And when the inspection found drills, radio and chart deficiencies, what triggered a wider examination of how safety was actually managed?
Does your inspection process verify the vessel’s condition, or does it also test the decisions that place the vessel there?
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