By Anna Lindsay
BBC News, Southampton
The initial coastguard response to the Ouzo yachting tragedy in which three sailors lost their lives was "seriously inadequate", according to an internal Maritime and Coastguard Agency (MCA) report seen by BBC News.
The Coastguard response to the tragedy was "seriously inadequate"
A catalogue of serious mistakes were made, which included failing to begin even a routine helicopter search for the men for six hours.
It later transpired that, despite the shortcomings, the sailor's lives could not have been saved.
But in the report, the MCA acknowledged that in other circumstances those failures could have contributed to "loss of life".
The report heavily criticises the way staff at the Solent Maritime Rescue Coordination Centre (MRCC Solent) reacted to news that a body had been found off the Isle of Wight, on the morning of Tuesday 22 August 2006.
The dead man was James Meaby, 36, who had been sailing from Bembridge, Isle of Wight, to Dartmouth onboard the 25ft (8.2m) yacht Ouzo with his two friends, Rupert Saunders, 36, and Jason Downer, 35.
A "fundamental error" was made in assuming the operation was "simply a single body recovery", the report said.
Most of the subsequent errors that were made were a result of this assumption, the report said.
• Only beginning a helicopter search for other possible survivors after six hours.
• Failing to broadcast to other shipping in the area to join in a search effort for other possible survivors.
• At midnight they failed again to search for survivors after the girlfriend of Mr Meaby contacted MRCC Solent to express concern that he and his two friends had not arrived at their destination.
• Ignoring police advice that the discovery of the body suggested a yacht could have been sunk.
• Failing to instruct the fishing vessel that found Mr Meaby's body to pull him out of the water to see if there was any chance of resuscitation.
All three sailors drowned after Ouzo sank in the early hours of Monday 21 August 2006.
Ferry officer Michael Hubble, 62, has been cleared of the manslaughter of the three men through gross negligence and charges of endangering life under the Merchant Shipping Act.
He was accused of failing to stop the towering 37,500-ton P&O ferry Pride of Bilbao after a close encounter with a yacht off the Isle of Wight.
He always maintained that the yacht was not Ouzo and that it had passed by safely.
Mr Meaby's body was found more than 24 hours later, at about 1100 BST on Tuesday 22 August.
It was assumed by the deputy watch manager at MRCC Solent that the body might be that of a fisherman reported missing off Barfleur in France several days earlier.
"From the outset, MRCC Solent regarded this as a 'body recovery' rather than a 'search and rescue' incident," the MCA report criticised.
Helicopters did not begin searching for other possible survivors until 1740 BST, when the neighbouring Maritime Rescue Coordination Centre at Portland (MRCC Portland) was "sufficiently concerned to inform the Duty Area Officer".
The report also criticised the standing-down of the helicopter search at 2100 BST, even though there was "still no information as to where the person found had come from, or whether he had been alone".
At 2345 BST, Mr Meaby's girlfriend contacted MRCC Solent to express her concerns. She feared media descriptions of the body and clothing matched that of her boyfriend.
'Measure of complacency'
Only when the Duty Area Officer was told of this development at 0513 BST did a full-scale search for Ouzo and her crew begin involving an RAF Nimrod maritime patrol aircraft, two Coastguard helicopters, two Royal Navy minesweepers, two RNLI lifeboats and five Coastguard Rescue teams ashore.
Later that day the bodies of Mr Saunders and Mr Downer were found - more than 48 hours after Ouzo got into difficulty.
A number of factors may have been to blame including a shortfall in training, a "measure of complacency" or other work distractions, the report said.
A major search involving the Royal Navy and RAF eventually began
The MCA's acting head of search and rescue, David Jardine-Smith, said the organisation had revised its working practices and training as a direct result.
"I would like to take this opportunity to express our deepest sympathy to the families of the three crew and indeed to apologise for the fact that this must have caused them extra pain," he said.
"As always we are determined to learn lessons," Mr Jardine-Smith added.
"We review the incidents we're involved in - picking up the good things we do as well as the things we don't do well.
"We did make mistakes but those mistakes had no effect on the outcome."