20 Dec 2024 David John Haw · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 8 Lack of required pre-journey safety briefings on pleasure vessels View source Use of support boats as taxis for event-related social transport View source Lack of specific guidance on support-boat responsibilities at sailing events View source Lack of legal requirement to wear lifejackets View source Failure to require carriage of personal flotation devices on all vessels View source Failure of vessel owners and operators to know support-boat use and passenger identity View source Lack of prohibition on helming pleasure vessels under the influence of alcohol or drugs View source Lack of equivalent safety mitigation for pleasure vessels used in commercial-like conditions View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Haw · 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
David John Haw was thrown from a support RHIB after it collided with a buoy in Poole Harbour at approximately 30 knots on 2 May 2022. He was recovered from the water on 14 May 2022, and the inquest recorded drowning and concluded unlawful killing. The concerns include differing safety requirements for pleasure and commercial vessels, alcohol use by pleasure-vessel helms, the absence of requirements for lifejackets on some vessels, and the use and regulation of support boats at sailing events.
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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Lack of required pre-journey safety briefings on pleasure vessels
Wider context from the report “Vessels that operate on the water are categorised as either pleasure or commercial vessels under current legislation and the legal requirements governing the design, construction and operation are very different, with commercial vessels being more heavily regulated. The definition of a pleasure vessel is provided under Regulation 2 of The Merchant Shipping (Vessels in Commercial Use for Sport or Pleasure) Regulations 1998 and any vessel that does not meet the definition under regulation 2, is a commercial vessel.
I have concerns that pleasure vessels are being used in a manner, and in conditions, that would be very similar to commercial vessels without the same safety mitigation. For example, there is no requirement to have a safety briefing prior to a journey on a pleasure vessel , whereas there is on a commercial vessel, however the risks may be the same, which can include death.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Use of support boats as taxis for event-related social transport
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events , albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware, as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats. I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events, which could lead to a future death.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance on support-boat responsibilities at sailing events
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events, albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware, as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats . I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events , which could lead to a future death.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Lack of legal requirement to wear lifejackets
Wider context from the report “Further, I have a concern that personal floatation devices, such as lifejackets or buoyancy aids are not legally required to be carried on all vessels, nor is there any legal requirement to wear lifejackets . The current legislation, The Merchant Shipping (Life-Saving Appliances and Arrangements) Regulations 2020, only requires pleasure vessels of over 13.7 metres in length to carry lifesaving appliances. I have concern that the lack of life saving appliances on all vessels could lead to future deaths.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Failure to require carriage of personal flotation devices on all vessels
Wider context from the report “Further, I have a concern that personal floatation devices, such as lifejackets or buoyancy aids are not legally required to be carried on all vessels , nor is there any legal requirement to wear lifejackets. The current legislation, The Merchant Shipping (Life-Saving Appliances and Arrangements) Regulations 2020, only requires pleasure vessels of over 13.7 metres in length to carry lifesaving appliances . I have concern that the lack of life saving appliances on all vessels could lead to future deaths.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Failure of vessel owners and operators to know support-boat use and passenger identity
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events, albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware , as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats. I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events, which could lead to a future death.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Lack of prohibition on helming pleasure vessels under the influence of alcohol or drugs
Wider context from the report “Further in relation to pleasure vessels, there is currently no legislation prohibiting the use of alcohol or drugs by those who are helming a vessel for private or pleasure use , whereas for those helming a commercial vessel, there is. The Railways and Transport Safety Act 2003 was enacted on 10th July 2003. Section 78 & 79 of that Act created an offence for professional mariners to perform their duties if impaired by alcohol, with Section 81 setting a prescribed limit for alcohol consumption. This position is very similar to an offence of driving a motor vehicle under the influence of alcohol. Under Section 80(3) there is a specific offence applicable to non-professional mariners of operating a vessel underway whilst under the influence of alcohol or drugs, however it is not currently in force. Accordingly, it is not illegal to helm a pleasure vessel under the influence of alcohol or drugs . Helming a vessel under the influence of alcohol or drugs could lead to a future death given the impact alcohol and drugs has upon perception, control, judgement and decision making.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Lack of equivalent safety mitigation for pleasure vessels used in commercial-like conditions
Wider context from the report “Vessels that operate on the water are categorised as either pleasure or commercial vessels under current legislation and the legal requirements governing the design, construction and operation are very different, with commercial vessels being more heavily regulated. The definition of a pleasure vessel is provided under Regulation 2 of The Merchant Shipping (Vessels in Commercial Use for Sport or Pleasure) Regulations 1998 and any vessel that does not meet the definition under regulation 2, is a commercial vessel.
I have concerns that pleasure vessels are being used in a manner, and in conditions, that would be very similar to commercial vessels without the same safety mitigation . For example, there is no requirement to have a safety briefing prior to a journey on a pleasure vessel, whereas there is on a commercial vessel, however the risks may be the same, which can include death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Gather evidence with event Organising Authorities to establish support-boat safety trends and identify proportionate responses.
Verbatim wording from the response “4) Use of Support Boats
The RYA is concerned by any adverse perceptions around particular boating activities. Accordingly, the RYA will be talking to a range of event Organising Authorities to gather evidence around the use of support boats to establish if the perception around a poor culture associated with support boats is accurate, and if so, what steps are proportionate address this.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage Organising Authorities to use safety management systems and implement event-specific measures to manage identified risks.
Verbatim wording from the response “While the RYA does not believe it appropriate for an Organising Authority to be required to influence the behaviour of boats in the vicinity of an event, such as boats unconnected with the event or boats used after hours or after the event has finished, the RYA is actively encouraging all Organising Authorities to have safety management systems in place for their activities. A safety management system should include consideration of applicable risks and detail the steps taken to minimise the risks identified. This will vary by event; however, the RYA is aware that some Organising Authorities of events in coastal areas have already considered laying on water taxis between venues or to return crews to competing yachts and therefore reduce the need for private boats to be used for transferring people.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional regulation is unlikely to have changed the outcome because existing vessel regulations and local speed restrictions were ignored.
Verbatim wording from the response “From a practical perspective, while the RYA notes the tragic circumstances of this case, the RYA questions if increased regulation would have changed the outcome, and notes that existing regulations applicable to the boat, including Section 100 of the Merchant Shipping Act, and a range of local byelaws, including a speed limit were ignored. Accordingly, the benefit of subjecting such vessels to additional regulation would appear to have limited benefit in comparison to raising awareness of the need to operate a boat in a safe and responsible way, irrespective of any underlying regulation.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MCA and relevant harbour authorities are responsible for regulating recreational and small commercial vessel operations.
Verbatim wording from the response “Whilst the RYA has the authority to determine the standards for its courses and for the conditions under which RYA recognised training centres operate, it does not have the authority to determine or enforce standards for operations within either the recreational sector or small commercial vessel sector. This responsibility falls to the MCA as the UK maritime regulator, and to local harbour authorities who have certain powers within their respective jurisdiction.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational standards for recreational and small commercial vessels are outside the respondent’s authority.
Verbatim wording from the response “Whilst the RYA has the authority to determine the standards for its courses and for the conditions under which RYA recognised training centres operate, it does not have the authority to determine or enforce standards for operations within either the recreational sector or small commercial vessel sector. This responsibility falls to the MCA as the UK maritime regulator, and to local harbour authorities who have certain powers within their respective jurisdiction.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The respondent cannot mandate particular support-boat provisions because each organising authority determines its event requirements.
Verbatim wording from the response “The Racing Rules of Sailing (as set by World Sailing) provide that an Organising Authority should issue a Notice of Race and go on to detail what an Event Organiser should include in that Notice of Race. Accordingly, it is for each Organising Authority to determine what is appropriate for its own event, and the RYA is unable to mandate particular provisions.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decisions to mandate lifejacket carriage for all vessels belong to the Secretary of State for Transport, not the respondent.
Verbatim wording from the response “Any decision to mandate the carriage of personal flotation devices for all vessels would be a matter for the Secretary of State for Transport and not for the RYA. The practical difficulties of enforcing the carriage of lifejackets are highlighted, given that pleasure vessels are not subject to the same inspection regime as commercial vessels, and it is also noted that the existing legislation applicable to commercial vessels does not mandate the wearing of a lifejacket unless there is an emergency or risk of entering the water, and accordingly applying the commercial standard would not result in a blanket requirement to wear a lifejacket or buoyancy aid. Therefore, the RYA remains of the opinion that the need to wear a lifejacket or buoyancy aid on a pleasure vessel is best communicated via education and training rather than legislation.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing legislation and harbour bylaws provide appropriate means to address alcohol-related safety concerns in recreational boating.
Verbatim wording from the response “The RYA notes that while there is no specific offence relating to the operation of a pleasure vessel while under the influence of alcohol, Section 100 of the Merchant Shipping Act 1995 imposes an obligation on the owner of a ship to take all reasonable steps to secure that the ship is operated in a safe manner. Accordingly, if a vessel is operated in an unsafe way as a result of alcohol, the owner of that vessel may be prosecuted. Focusing on the impact on safety rather than imposing an arbitrary alcohol limit allows for a more flexible approach to be taken and ultimately would allow action to be taken even if a maximum alcohol limit had not been reached.” Source location Response from Royal Yachting Association
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Unsafe or impermissible boats near events are matters for the relevant harbour authority, not event organising authorities.
Verbatim wording from the response “The RYA acknowledges that events held in public waters often see a number of boats in the vicinity of the event, but notes that these may be spectator boats or general water users and may not fall within the definition of support boat, or indeed, be part of the event. The RYA wishes to encourage the safety of all water users, and therefore imposing requirements on event Organising Authorities is not felt to be a holistic solution, or indeed effective given an Organising Authority has no jurisdiction over boats outside of their events. If it is believed that boats in the vicinity of an event are operating either unsafely or in breach of the existing definition of pleasure vessel, then this is a matter for the relevant harbour authority and not the Organising Authority.” Source location Response from Royal Yachting Association
Open published response
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
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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 Royal Yachting Association; 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
14 Dec 2016 Liam Day · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Lack of means to request help during climbing over deep water View source Dangerously low temperatures in coastal waters View source Failure to wear a lifejacket or buoyancy aid when climbing over deep water View source Failure to leave specific location and return-time instructions for climbing activities View source Failure to use a safety line when climbing over deep water View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liam Day · 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
Liam Day left home to go climbing on 15 June 2016 and failed to return; his body was recovered from the water on 28 June 2016, with the cause of death given as hypothermia following a fall into the sea. The report raised concerns about his lack of safety equipment, warm clothing, means of seeking help and specific plans, and highlighted the dangers of cold coastal water to people participating in water-based climbing activities.
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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Lack of means to request help during climbing over deep water
Wider context from the report “Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:-
1. He was climbing with no safety line
2. He was not wearing a lifejacket or buoyancy aid
3. He was not wearing clothing that offered no warmth in the water
4. He was not on his own
5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio
6. He had left no specific instructions as to where he was intending to climb and what time he would be home
The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report.
During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Dangerously low temperatures in coastal waters
Wider context from the report “Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:-
1. He was climbing with no safety line
2. He was not wearing a lifejacket or buoyancy aid
3. He was not wearing clothing that offered no warmth in the water
4. He was not on his own
5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio
6. He had left no specific instructions as to where he was intending to climb and what time he would be home
The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report.
During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Failure to wear a lifejacket or buoyancy aid when climbing over deep water
Wider context from the report “Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:-
1. He was climbing with no safety line
2. He was not wearing a lifejacket or buoyancy aid
3. He was not wearing clothing that offered no warmth in the water
4. He was not on his own
5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio
6. He had left no specific instructions as to where he was intending to climb and what time he would be home
The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report.
During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Failure to leave specific location and return-time instructions for climbing activities
Wider context from the report “Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:-
1. He was climbing with no safety line
2. He was not wearing a lifejacket or buoyancy aid
3. He was not wearing clothing that offered no warmth in the water
4. He was not on his own
5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio
6. He had left no specific instructions as to where he was intending to climb and what time he would be home
The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report.
During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight.
” 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 Royal Yachting Association; that does not assign responsibility.
PFD Monitor interpretation Failure to use a safety line when climbing over deep water
Wider context from the report “Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:-
1. He was climbing with no safety line
2. He was not wearing a lifejacket or buoyancy aid
3. He was not wearing clothing that offered no warmth in the water
4. He was not on his own
5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio
6. He had left no specific instructions as to where he was intending to climb and what time he would be home
The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report.
During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh website safety information pages, prominently featuring cold water shock guidance.
Verbatim wording from the response “Within the sports that the RYA represents, the value of wearing a lifejacket or buoyancy aid and appropriate clothing is reasonably widely recognised. Nevertheless, the RYA has recently refreshed the safety information pages on its website (www.rya.org.uk/go/safety) and cold water shock appears prominently on the first page (under “look after yourself”). The RYA will be highlighting this safety information to its members through various electronic communications in the early part of this year, as well as in the RYA’s annual Safety Advisory Notice.” Source location 2016-0402-Response-by-RYA
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight safety information to members through electronic communications and the annual Safety Advisory Notice.
Verbatim wording from the response “Within the sports that the RYA represents, the value of wearing a lifejacket or buoyancy aid and appropriate clothing is reasonably widely recognised. Nevertheless, the RYA has recently refreshed the safety information pages on its website (www.rya.org.uk/go/safety) and cold water shock appears prominently on the first page (under “look after yourself”). The RYA will be highlighting this safety information to its members through various electronic communications in the early part of this year, as well as in the RYA’s annual Safety Advisory Notice.” Source location 2016-0402-Response-by-RYA
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lifejackets, buoyancy aids and warm clothing could create significant hazards during climbing, increasing the likelihood of falling.
Verbatim wording from the response “Although the RYA has no remit for mountaineering it seems to us that a lifejacket or buoyancy aid and the sort of clothing that offers warmth in water would present a significant hazard to the wearer while climbing, particularly “Deep Water Soloing”, and in fact increase the likelihood of the wearer falling.” Source location 2016-0402-Response-by-RYA
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mountaineering falls outside the respondent’s remit, so it does not undertake responsive safety work for that activity.
Verbatim wording from the response “Although the RYA has no remit for mountaineering it seems to us that a lifejacket or buoyancy aid and the sort of clothing that offers warmth in water would present a significant hazard to the wearer while climbing, particularly “Deep Water Soloing”, and in fact increase the likelihood of the wearer falling.” Source location 2016-0402-Response-by-RYA
Open published response
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
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Royal Yachting Association; 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
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations