Concerns raised 12 Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft View source Lack of proper protection for passengers and crew from impact and vibration hazards View source Non-uniform risk management for high-speed rides View source Confusing and inconsistent requirements and guidance for small-craft operators View source Insufficient crewing for lookout and skipper workload control View source Delays in revising codes of practice for high-speed craft View source Loss of situational awareness during RIB operations View source Inadequate seating and collision-impact mitigation in RIBs View source Inadequate forward visibility from passenger-carrying RIBs View source Failure to ensure timely and comprehensive review of MAIB recommendations View source Unavailability of AIS capability for monitoring RIB operations View source Excessive piloting workload during high-speed RIB operations View source See 9 more concerns
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Emily Jane LEWIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emily Jane Lewis, aged 15, died at Southampton General Hospital on 22 August 2020 after the high-speed RIB on which she was a passenger collided with a buoy, projecting her into a handhold and causing fatal injuries. The principal concerns included the workload and situational awareness of a lone skipper, inadequate forward visibility and passenger protection, shortcomings in seating and handrail design, insufficient risk assessment and safety management, and confusing or inconsistent regulation of high-speed RIB experience rides.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Lack of proper protection for passengers and crew from impact and vibration hazards
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Non-uniform risk management for high-speed rides
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides .
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Confusing and inconsistent requirements and guidance for small-craft operators
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Insufficient crewing for lookout and skipper workload control
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Delays in revising codes of practice for high-speed craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back : the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond . The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Loss of situational awareness during RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Inadequate seating and collision-impact mitigation in RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions , noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Inadequate forward visibility from passenger-carrying RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely and comprehensive review of MAIB recommendations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AIS capability for monitoring RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS) . There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Excessive piloting workload during high-speed RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report
11 Jan 2016 Emily Charlotte Milligan and Nicholas Desmond Robertson Milligan · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1 Additional risks from increased speed and power of power boat leisure craft View source
Responses linked to these concerns
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AI-generated summary
Emily Charlotte Milligan and Nicholas Desmond Robertson Milligan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 5 May 2013, Emily Milligan and Nicholas Milligan were fatally injured after being ejected from a powerboat in the Camel Estuary; the boat continued to circle and struck them. The report identified increased speed and power in leisure powerboats as creating additional risks for users.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Marine Federation; that does not assign responsibility.
PFD Monitor interpretation Additional risks from increased speed and power of power boat leisure craft
Wider context from the report “There has been an increase in the speed/power of such power boat leisure craft which create additional risks which users should be aware of to prevent accidents.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations