Wayne Andrew ROGERS · Prevention of Future Deaths report

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Issued 28 Mar 2019•Isle of Wight

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
7

Described in responses

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.

Report evidence summary

Concerns raised5

  1. Failure to monitor and record safety channels for incident response
  2. Failure to coordinate manpower for incident response
  3. Insufficient ambulance capacity for emergency incidents during major events
    Part of recurring concern: Insufficient ambulance service capacity for emergency calls

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Cowes Week Limited

    Assess making an automated external defibrillator available directly at the Trinity Landing pontoon.

  2. Cowes Week Limited

    Implement safety-channel monitoring and recording arrangements with independent safety radio monitors and race radio operators.

  3. Cowes Week Limited

    Communicate relevant safety recommendations, including the need for suitable onboard knives, through sailing instructions and safety booklets.

  4. Cowes Week Limited

    Communicate the potential risk from continuous spinnaker sheets and address it in the safety booklet.

  5. Cowes Week Limited

    Discuss additional ambulance support internally and report back on the proposal.

  6. Cowes Week Limited

    Review strong-wind and incident race-abandonment criteria, including alternative mainland casualty drop-off points.

  7. Cowes Week Limited

    Review options for placing automated external defibrillators on larger control vessels.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Cowes Week Limited

    Ensuring all boats carry suitable knives is outside the organiser’s control, although recommendations will be communicated to competitors.

    Outside remitThe respondent said that this matter was outside its role or authority.
  2. Cowes Week Limited

    Without accepted standards for knife numbers, locations or boat sizes, defining suitable requirements is difficult for the organiser.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Cowes Week Limited

    Practical constraints make placing AEDs on small rescue craft impractical, while stopping at larger vessels would delay returning casualties ashore.

    Unable 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

Failure to monitor and record safety channels for incident response

Wider context from the report

“4) A review needs to be carried out of the Crisis Management Plan, with an emphasis on monitoring and recording of safety channels and manpower coordination for incident response. ”

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 coordinate manpower for incident response

Wider context from the report

“4) A review needs to be carried out of the Crisis Management Plan, with an emphasis on monitoring and recording of safety channels and manpower coordination for incident response. ”

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

Insufficient ambulance capacity for emergency incidents during major events

Wider context from the report

“1) I was informed that during the course of Cowes Week Sailing Festival that there are approximately 7,000 competitors who travel to Cowes on the Isle of Wight to participate in the various events. In this instance, it was fortunate that an ambulance was available to convey the casualty to the hospital as an emergency. However, there are a finite number of ambulances on the Isle of Wight, and they are often overstretched to carry out routine work, without the possibility of an incident happening during this Sailing Festival. ”

Is this part of a recurring concern?

Yes — Insufficient ambulance service capacity for emergency calls.

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

Inadequate criteria for abandoning racing during a major incident

Wider context from the report

“6) A review needs to be carried out of the criteria for abandoning racing in the event of a major incident. ”

Is this part of a recurring concern?

Yes — Unreliable decisions to start, stop or abandon racing.

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

Omission of readily accessible safety knives from mandatory safety equipment requirements

Wider context from the report

“5) A review needs to be carried out of the published list of mandatory safety equipment, including mention of readily accessible safety knives. ”

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

Assess making an automated external defibrillator available directly at the Trinity Landing pontoon.

Verbatim wording from the response

“3) With regards to Automated External Defibrillators, this is under review. It is not practical to have AED’s on small rescue craft which are subject to being wet much of the time and we only have a limited number of bigger control vessels with dry cabins during the week. We will review the options of putting AED’s on some of those boats but our initial thoughts are that a delay in returning a casualty to shore are highly unlikely to make stopping off at a larger committee boat on the water practical. There are already several AED’s within 90 seconds of the Trinity Landing pontoon (the emergency drop off point for on water causalities) and we will look at making one available directly on the pontoon as well.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 1 · response
Published 9 June 2019

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

Implement safety-channel monitoring and recording arrangements with independent safety radio monitors and race radio operators.

Verbatim wording from the response

“4) I can confirm that we have fully taken on board all of the recommendations in the investigative report with regards to monitoring and recording safety channels as well as the manpower requirements.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 1 · response
Published 9 June 2019

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

Communicate relevant safety recommendations, including the need for suitable onboard knives, through sailing instructions and safety booklets.

Verbatim wording from the response

“5) Some of the recommendations are outside our control in terms of delivery (as an example the fact that all boats should carry suitable knives) but despite that being the case we will be making the recommendations known to our competitors, both through our sailing instructions (where appropriate) and our safety booklet where appropriate. There are no accepted standards for how many knives should be carried, in what locations, on what size of boat, so we think it would be difficult for Cowes week to lead the way in trying to define that. Nonetheless the necessity to have a sharp knife on board, whilst being known to most sailors, is something that we will reinforce.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 2 · response
Published 9 June 2019

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

Communicate the potential risk from continuous spinnaker sheets and address it in the safety booklet.

Verbatim wording from the response

“7) We are making known the issue that continuous spinnaker sheets may have played a part in this incident and this will be addressed in our safety booklet going forward.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 2 · response
Published 9 June 2019

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

Discuss additional ambulance support internally and report back on the proposal.

Verbatim wording from the response

“1) With regards to the additional ambulance support proposal, this is something that we are discussing internally and on which I will revert to you on.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 1 · response
Published 9 June 2019

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

Review strong-wind and incident race-abandonment criteria, including alternative mainland casualty drop-off points.

Verbatim wording from the response

“6) We are reviewing again the criteria for abandoning racing in the case of strong winds and / or an incident. We feel this worked well in 2018 but further work is being undertaken in this regard to ensure that any lessons learned are taken on board. In particular we are looking at alternative drop off points for casualties on the mainland, if that is nearer to an incident location or is an easier location to reach in certain wind conditions. This was not the case in this instance.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 2 · response
Published 9 June 2019

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

Review options for placing automated external defibrillators on larger control vessels.

Verbatim wording from the response

“3) With regards to Automated External Defibrillators, this is under review. It is not practical to have AED’s on small rescue craft which are subject to being wet much of the time and we only have a limited number of bigger control vessels with dry cabins during the week. We will review the options of putting AED’s on some of those boats but our initial thoughts are that a delay in returning a casualty to shore are highly unlikely to make stopping off at a larger committee boat on the water practical. There are already several AED’s within 90 seconds of the Trinity Landing pontoon (the emergency drop off point for on water causalities) and we will look at making one available directly on the pontoon as well.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 1 · response
Published 9 June 2019

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

Ensuring all boats carry suitable knives is outside the organiser’s control, although recommendations will be communicated to competitors.

Verbatim wording from the response

“5) Some of the recommendations are outside our control in terms of delivery (as an example the fact that all boats should carry suitable knives) but despite that being the case we will be making the recommendations known to our competitors, both through our sailing instructions (where appropriate) and our safety booklet where appropriate. There are no accepted standards for how many knives should be carried, in what locations, on what size of boat, so we think it would be difficult for Cowes week to lead the way in trying to define that. Nonetheless the necessity to have a sharp knife on board, whilst being known to most sailors, is something that we will reinforce.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 2 · response
Published 9 June 2019

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

Without accepted standards for knife numbers, locations or boat sizes, defining suitable requirements is difficult for the organiser.

Verbatim wording from the response

“5) Some of the recommendations are outside our control in terms of delivery (as an example the fact that all boats should carry suitable knives) but despite that being the case we will be making the recommendations known to our competitors, both through our sailing instructions (where appropriate) and our safety booklet where appropriate. There are no accepted standards for how many knives should be carried, in what locations, on what size of boat, so we think it would be difficult for Cowes week to lead the way in trying to define that. Nonetheless the necessity to have a sharp knife on board, whilst being known to most sailors, is something that we will reinforce.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 2 · response
Published 9 June 2019

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

Practical constraints make placing AEDs on small rescue craft impractical, while stopping at larger vessels would delay returning casualties ashore.

Verbatim wording from the response

“3) With regards to Automated External Defibrillators, this is under review. It is not practical to have AED’s on small rescue craft which are subject to being wet much of the time and we only have a limited number of bigger control vessels with dry cabins during the week. We will review the options of putting AED’s on some of those boats but our initial thoughts are that a delay in returning a casualty to shore are highly unlikely to make stopping off at a larger committee boat on the water practical. There are already several AED’s within 90 seconds of the Trinity Landing pontoon (the emergency drop off point for on water causalities) and we will look at making one available directly on the pontoon as well.”

Source location

2019-0105-Response-by-Cowes-Week-Limited
Page 1 · response
Published 9 June 2019

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

Official responses located
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Data last updated 7 September 2026