PFD report

Michael Holgate · Prevention of Future Deaths report

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Issued 4 Jul 2014•Stoke-on-Trent and North Staffordshire

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
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised3

  1. Lack of communication means within the tunnel
    Part of recurring concern: Unreliable access to emergency communication
  2. Failure to provide safety information to all tunnel users
  3. Lack of requirement for persons in the tunnel to wear safety jackets or buoyancy aids
    Part of recurring concern: Inadequate lifejacket safety controls for watercraft users
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.5

  1. Action

    Continue encouraging boaters to wear lifejackets or buoyancy aids, particularly in tunnels.

    Stated by Canal & River TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2014.
  2. Action

    Complete the review of practicable in-tunnel communication systems.

    Stated by Canal & River TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2014.
  3. Action

    Modify the Harecastle Tunnel briefing to emphasise lifejackets and explain temperature changes inside the tunnel.

    Stated by Canal & River TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2014.

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

  1. Position

    The in-tunnel communication study could not be completed by the requested deadline because of its complexity.

    Stated by Canal & River TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Lack of communication means within the tunnel

Wider context from the report

“1. There is no means of communication within the tunnel, I accept that mobile phones are not the like work but I would ask the Trust to explore the possibility of a telephone cable and a number of emergency telephones at strategic or regular points within the tunnel. ”

Is this part of a recurring concern?

Yes — Unreliable access to emergency communication.

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 provide safety information to all tunnel users

Wider context from the report

“4. I would ask generally that there be a review of the safety information given out, and made available to all, not just those driving the narrow boats. ”

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

Lack of requirement for persons in the tunnel to wear safety jackets or buoyancy aids

Wider context from the report

“2. There is no requirement to wear safety jackets/buoyancy aids in the tunnel. These are mandated for narrow boat owners to carry on the boats. Would it not be possible to insist that all persons on board wear such safety equipment before they are allowed into the tunnel? ”

Is this part of a recurring concern?

Yes — Inadequate lifejacket safety controls for watercraft users.

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

Continue encouraging boaters to wear lifejackets or buoyancy aids, particularly in tunnels.

Verbatim wording from the response

“2. Wearing of lifejackets or buoyancy aids There is no mandatory requirement that lifejackets or buoyancy aids must be worn or carried on inland waterway vessels. The Trust does encourage their use on inland waterways, but the general view of many inland waterway boaters is that lifejackets or buoyancy aids are unnecessary, but this is an attitude that the Trust is trying to change. The Trust will continue to encourage boaters to wear them in the interests of their general safety whilst boating, and we will make particular reference to safety in tunnels. In direct response to this tragedy we will be encouraging the wearing of lifejackets at Harecastle Tunnel by means of the briefing given to boaters and their crew prior to tunnel entry.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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

Complete the review of practicable in-tunnel communication systems.

Verbatim wording from the response

“at the tunnel during its operating hours. We are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31st March 2015.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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

Modify the Harecastle Tunnel briefing to emphasise lifejackets and explain temperature changes inside the tunnel.

Verbatim wording from the response

“4. Review of safety information given out The Harecastle tunnel briefing has been further modified to make clear the importance of wearing lifejackets particularly for the helmsman. Additional information about change of temperature in the tunnel is being included in the briefing as this has been identified as a particular risk of which boaters should be aware. These changes have been made.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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

Modify tunnel portal signs across the network to recommend wearing lifejackets.

Verbatim wording from the response

“As the majority of tunnels are unattended by Trust staff we will modify all existing tunnel portal signs to include a clear recommendation to wear lifejackets. Additionally we will conduct an education campaign using our communication channels with boaters, about benefits of wearing of lifejackets/buoyancy aids. Although part of a continuous campaign we will complete this initial work by the 31st March 2015 which is the start of the main boating season.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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

Conduct an education campaign through boater communication channels about lifejacket and buoyancy-aid benefits.

Verbatim wording from the response

“As the majority of tunnels are unattended by Trust staff we will modify all existing tunnel portal signs to include a clear recommendation to wear lifejackets. Additionally we will conduct an education campaign using our communication channels with boaters, about benefits of wearing of lifejackets/buoyancy aids. Although part of a continuous campaign we will complete this initial work by the 31st March 2015 which is the start of the main boating season.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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 in-tunnel communication study could not be completed by the requested deadline because of its complexity.

Verbatim wording from the response

“at the tunnel during its operating hours. We are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31st March 2015.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Replace Harecastle Tunnel’s chain gauge board with a physical board highlighting restricted headroom.

    Stated by Canal & River TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2014.
  2. 2

    Conduct a review of tunnel safety and operational procedures across Harecastle and the Trust’s other canal tunnels.

    Stated by Canal & River TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Issuing safety helmets is not considered an appropriate response to restricted tunnel headroom risks.

    Stated by Canal & River TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    After completing the outlined actions, all reasonably practicable measures will have been taken to reduce tunnel navigation risks.

    Stated by Canal & River TrustNo action considered necessaryThe respondent said that no further action was needed.

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

Replace Harecastle Tunnel’s chain gauge board with a physical board highlighting restricted headroom.

Verbatim wording from the response

“Prior to entering the tunnel the ‘gauge board’ at Harecastle consists of 3 lightweight chains. We believe these may not be as effective as other alternative measures in making boaters aware of the restrictions inside the tunnel. At other tunnels with similar restrictions on headroom we have physical boards prior to entry. We have concluded that we will replace the chains with a physical board positioned prior to entering the tunnel to put greater emphasis on the restricted headroom. The tunnel portal is a listed building but we plan to complete this work subject to planning consent by 31st March 2015.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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

Conduct a review of tunnel safety and operational procedures across Harecastle and the Trust’s other canal tunnels.

Verbatim wording from the response

“On the 26th of August the Canal and River Trust conducted a review of tunnel safety and operational procedures relevant to the incident which led to Mr Holgate’s death. In addition we considered what changes should be made, not only at Harecastle, but at all our 45 canals.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 1 · response
Published 4 August 2014

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

Issuing safety helmets is not considered an appropriate response to restricted tunnel headroom risks.

Verbatim wording from the response

“3. Wearing of safety helmets We do not believe that issuing safety helmets is an appropriate response to the restricted headroom in tunnels. The risks at Harecastle Tunnel are not unique, as in many tunnels if the centre line is not followed when navigating, there is a risk of helmsman or crew members striking their head on the shoulders of the tunnel bore, irrespective of any other restriction in headroom.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

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

After completing the outlined actions, all reasonably practicable measures will have been taken to reduce tunnel navigation risks.

Verbatim wording from the response

“It is our considered opinion that once the actions outlined above have been completed, the Trust will have done all that is reasonably practicable to reduce the risk to persons navigating boats through Harecastle and other canal tunnels.”

Source location

2014-0357-Response-by-Canal-River-Trust
Page 2 · response
Published 4 August 2014

Open published response
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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