The likely cause of a trawler capsizing and sinking off the Canterbury coast with the loss of all three fishermen aboard had happened on a previous fishing trip just days earlier, it's been revealed.
The 90-tonne, 16m Jubilee sank 22km off the Rakaia River mouth after sending a distress signal early on October 18, 2015.
All three experienced fishermen on board - Jared Reese Husband, 47, of Timaru, skipper Paul Russell Bennett, 35, of Motueka, and 55-year-old Terry Donald Booth also from the Nelson region – died.
A Transport Accident Investigation Commission (TAIC) probe concluded the sinking was likely caused by a hose left running – and that the men had been trapped inside the wheelhouse without any escape route.
Now, it's been revealed that on an October 9-15 trip, just days before the fatal sinking - disaster was narrowly averted.
According to court documents obtained by the Herald on Sunday, the fish room had flooded when a hose was accidentally left on.
However, the hose was discovered and it took crew "some time to clear the fish room".
The room only had one pump - which had no alarm to alert crew members to flooding - and was known to block with fish scales, requiring regular cleaning.
"The vessel was observed as being noticeably lower in the stern with the water in the fish room," says a document in the Maritime New Zealand case against the Jubilee's operators, Ocean Fisheries.
The Lyttelton-based company, where Andrew Stark is the chief executive, has pleaded guilty to one charge, laid under the Health and Safety in Employment Act 1992, of failing to ensure that no contractor was harmed while working. The charge carries a maximum penalty of $250,000 and the company will be sentenced next month.
Since the triple tragedy, Stark's companies have introduced a range of safety measures to its fleet, including a second pump and two high water alarm systems in the fish room of another of its boats, Legacy. An additional escape from the wheelhouse has been added along with a Perspex hatch, a life raft light, and a light to show if the loading hatch is open or shut.
Maritime NZ has also said Stark's companies have undergone "a significant overhaul of their health and safety practices". Stark told investigators that after the Jubilee's sinking, the companies had "racked their brains" to work out how it sunk and "anything they thought might be contributory they have doubled it".
In April 2017, TAIC recommended that Maritime NZ tellvessel ownersthe benefits of installing crew alerts for any abnormal rises in water levels in compartments, particularly ones that compromise buoyancy or stability.
TAIC also issued key lessons from the tragedy, including the need for vigilant watchkeeping, especially around the state of trim and stability of the vessel, and a risk-based approach to escape routes.
Several days after the sinking, the three bodies of the fishermen were recovered from the wheelhouse by Royal New Zealand Navy divers. One of the crew was fully clothed and the other two were dressed in what was probably sleeping attire. None was wearing lifejackets.
The Jubilee wreck has never been recovered from the seabed.