PFD report

Michael Robert Hanlon · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 23 Jul 2015•Cumbria

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure of the after-hours boat-entry system to provide reliable crew access
  2. Failure to manage additional shifts to prevent crew fatigue
  3. Failure to maintain accurate records of crew work patterns and hours
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Implement a 24-hour watch system when the owner or guests are aboard.

    Stated by Pluteus LimitedStated completedThe respondent said that this action was complete when they made their response on 23 July 2015.
  2. Action

    Install and operate a personal-code keyless entry system for crew access to the vessel.

    Stated by Pluteus LimitedStated completedThe respondent said that this action was complete when they made their response on 23 July 2015.
  3. Action

    Issue a Captain’s Standing Order establishing procedures to monitor working hours and rest periods and prevent additional work without requisite rest, except during safety emergencies.

    Stated by Pluteus LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 July 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The keyless entry system, backup call-in arrangements and 24-hour watch when guests are aboard adequately address the need for crew access keys.

    Stated by Pluteus LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of the after-hours boat-entry system to provide reliable crew access

Wider context from the report

“During the Inquest it became apparent that members of the crew had failed to gain entry to the boat on returning from on shore. One crewmember had slept on deck. I also concluded one crewmember had attempted to climb through a doorway on the upper deck near to the position where the deceased had fallen. There was a possibility, but no finding was made, that the deceased may have been endeavouring to enter the boat by this route when he fell. I also concluded crewmembers and in this case the deceased were likely to have been asked to work additional shifts when the boat came in to port, potentially causing tiredness amongst crewmembers. Further the deceased’s work pattern did not match the shift rota and his time sheet was not made up to the time of his last shift. The system for entering the boat after 10.00p.m involved certain members of the crew having a key, but otherwise requiring knowledge of a key code to obtain a key from a box situated at the front of the boat. The key could then be taken to the entry door at the rear of the boat, a door opened and then the key returned to the front of the boat in to the key box before the crewmember would then enter the open door. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to manage additional shifts to prevent crew fatigue

Wider context from the report

“I also concluded crewmembers and in this case the deceased were likely to have been asked to work additional shifts when the boat came in to port, potentially causing tiredness amongst crewmembers. Further the deceased’s work pattern did not match the shift rota and his time sheet was not made up to the time of his last shift. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain accurate records of crew work patterns and hours

Wider context from the report

“I also concluded crewmembers and in this case the deceased were likely to have been asked to work additional shifts when the boat came in to port, potentially causing tiredness amongst crewmembers. Further the deceased’s work pattern did not match the shift rota and his time sheet was not made up to the time of his last shift. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement a 24-hour watch system when the owner or guests are aboard.

Verbatim wording from the response

“Please also note that a 24 hour watch system is implemented in place of the keyless entry when the owner or guests are on board.”

Source location

2015-0294-Response-by-Pluteus-Limited
Page 2 · response
Published 23 July 2015

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

Install and operate a personal-code keyless entry system for crew access to the vessel.

Verbatim wording from the response

“As part of a refit programme, commencing in 2014, a new, “keyless”, entry system has now been installed (after some delays, in summer 2015) on board Faith whereby each crew member or arrival is issued with a personal access code (rather like a cash withdrawal PIN code), which they can choose themselves (thus making it more memorable), which is unique and personal to them and which should be kept confidential. This has removed the need for keys, which is the common form of access in yachts of Faith’s age.”

Source location

2015-0294-Response-by-Pluteus-Limited
Page 2 · response
Published 23 July 2015

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

Issue a Captain’s Standing Order establishing procedures to monitor working hours and rest periods and prevent additional work without requisite rest, except during safety emergencies.

Verbatim wording from the response

“In connection with the Second Action, a system of recording working hours and hours of rest is and has always been in place as per International Maritime Organisation and International Labour Organisation requirements. Given the concerns you have identified in the PFD, steps will be taken by the Captain by means of a Captain’s Standing Order to ensure appropriate procedures are put in place to monitor those working hours and to ensure that crew members are not working additional hours without the requisite rest periods, in particular between shifts, unless the safety of the boat, crew and passengers is in danger. The Captain’s Standing order is to be issued in the week beginning 31st August 2015.”

Source location

2015-0294-Response-by-Pluteus-Limited
Page 2 · response
Published 23 July 2015

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 keyless entry system, backup call-in arrangements and 24-hour watch when guests are aboard adequately address the need for crew access keys.

Verbatim wording from the response

“In connection with the First Action, Wright Maritime and the Captain have both commented that providing keys to seafarers for access outside of hours has proven to be unreliable, unsatisfactory and impossible to control, particularly because keys can be lost or forgotten. This can potentially lead to problems with access”

Source location

2015-0294-Response-by-Pluteus-Limited
Page 1 · response
Published 23 July 2015

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026