MAIB interim report on Seadogz fatality

[C2 RIBS]

Originally Posted by Pikey Dave

OK, I think we all know what everyone's position is on this. So moving on. In the interests of protecting the industry & its customers. Where (if any) would you like to see any changes to legislation & regulation happening? Would you support a tightening of the rules, and a change to the sentencing if when some thing like this happens again? Or in your opinion, should things remain "as is"?

Just did a full response with evidence of changes and the forum closed and lost input , I will do it again asap. Unless admins have saved that response

[C2 RIBS]

Originally Posted by Pikey Dave

OK, I think we all know what everyone's position is on this. So moving on. In the interests of protecting the industry & its customers. Where (if any) would you like to see any changes to legislation & regulation happening? Would you support a tightening of the rules, and a change to the sentencing if when some thing like this happens again? Or in your opinion, should things remain "as is"?

Sorry for delay as had to rewrite

Changes are already occurring and have been for two years and more.

Insurers
• Restrictions on speeds for passenger RIBs whilst carrying clients
• Refusing many new boats cover if they buy twin engine large engine RIBs
• Trackers on vessels to monitor all activity with access to insurers if they require
Industry changes started to occur after the Cheeki Rafiki tragedy in 2014 mid Atlantic with the loss of four lives on a sailing boat. There were legal arguments on this vessel and coding, MCA realised then they had a set of guidance notes called MGN280 that could not be legally enforced. MGN 280 is an amalgamation of all the colour codes into one document.

Brown Codes was dragged out of MGN 280 first and formatted as Work Boat Code ( many vessels have a dual code option) which has already gone through two rewrites and now on its third. It is first of codes to get legislation but the recent Work Boat 3 is just now under MCA review after going to Public Consolation after industry responses. The rest of MGN 280 is being formatted as another new code the Sport and Leisure Code- This is the drive to get it into legislation for our side of industry. Presently with industry professionals and MCA at review of each page. Even when that is done MCA have to send it to public consolation and then get it finalised for time in Parliament to pass legislation , Target date 2024 – bear in mind that is election year!!

More incidents involving ribs-
Osprey Rib Crash Scotland-July 2016- life changing injuries to passenger and a code certificate that was appalling allowing paying passengers to sit on tubes and not seating.

Rib crash in Buoy on river Thames July 2019- 8 injured and thrown in water in darkness, Vessel users believed they had more passengers than they did resulting in more rescue crews searching

Following the Osprey crash a group of industry and also MAIB and MCA sat down to review what operation documents were in place, At that time MGN 280 for coding of vessels ( guidance doc) then a High Speed voluntary code of practice from RYA and Passenger Boat Association(PBA) . ALL out of DATE! Images and instructions were nearly ten years old again. Other Charter groups (PCA Ltd) also formed new operational guidance docs for RIBs, This was formatted with the biggest RIB operator in UK and other operators from around the UK to improve safety from moment of booking through to the trip itself. During this time Shock Mitigation became a foremost update for many operators. From the MAIB run meeting with MCA a new document was requested from RYA and PBA- that took over 2 years to finish and publish HSPV code April 2019 Issue 3.

The industry has been working hard to put in place rules and regs but they come under the Dept of Transport and as you see it takes years despite the industry driving for more safety.

SOPs are now a standard approach for most operators with risk assessments covering all areas of operations. This was an area that was highlighted by marine experts at the recent trial.

Presently with insurance changes and new policies for operators introduced before this accident the industry has been improving and continues to do so. I know of plenty of reports to MCA about unsafe practices or unlicensed operations but the enforcement is poor. MCA state this accident was not as a result of failing to comply with the inspection code MGN 280 but highlighted the HSPV voluntary code failures

So do I support tightening of rules?> Yes 100% is my personal view and also think every use of any vessel should be licensed with training mandatory- yet this accident can hardly support that as fully licensed, high skilled skipper ( RNLI Coxswain trainer and RYA Advanced Power Boat Trainer).

Enforcement is a mega issue- lack of it, different rules for each area under local authorities or Ports, Categorised waters mean presently the MCA have little say or enforcement options as NOT AST SEA in definition terms. So MCA need to up their capability and start responding to information given to them and enforcement by ports and Harbour teams is no doubt going to be stepped up now after this accident

Sentencing is a matter for the criminal justice system. I heard the full facts on sentencing from the Judge and it was clear he was limited on custodial. There was also an issue that was not reported on a recent stated case March 2023- R V Ali- Stated:-

“You will appreciate that operating very close to prison capacity will have consequences for the conditions in which prisoners are held. More of them will be in crowded conditions while in custody, have reduced access to rehabilitative programmes, as well as being further away from home (affecting the ability for family visits). Prisoners held in police cells under Operation Safeguard will not have access to the full range of services normally offered in custody, including rehabilitative programmes.”

Other matters in the case also gave me a wider understanding of sentencing.

People have outlined other sentencing but this does not link into marine world and this accident. The judge gave very clear route to decisions for Jury and I guessed the outcome correctly from this. Point to prove in law are a big issue and must be proven to get a case home. I have spent years in and out of court processes so have a wide understanding of legal processes and evidence. Would I support changes to sentencing if this occurred again? I would only decide if I heard the facts, sorry media reporting was very unbalanced.
Things have not stayed as they were at the time of this accident and can honestly say have moved on a long way and we continue to strive for better processes, systems etc. Safety remains paramount for everyone. Will we stop accidents? Doubt it. look at our roads, heavily legislated and controlled and daily deaths around the UK occur, we don’t see this in the charter industry with thousands of trips each month. One accident involving passengers is one too many.

Since this accident I am aware of two other major accidents in marine industry of similar boats- Poole- 3rd May 2022- Fatal hitting a buoy at night, Totland Bay Sept 2022 a cruiser ran up rocky beach destroying boat at night and serious passenger injuries – Both ongoing criminal cases with police and MCA but both shown as private boating

[Iankristy]

Originally Posted by C2 RIBS

Sorry for delay as had to rewrite

Changes are already occurring and have been for two years and more.

Insurers
•Restrictions on speeds for passenger RIBs whilst carrying clients
•Refusing many new boats cover if they buy twin engine large engine RIBs
•Trackers on vessels to monitor all activity with access to insurers if they require
Industry changes started to occur after the Cheeki Rafiki tragedy in 2014 mid Atlantic with the loss of four lives on a sailing boat. There were legal arguments on this vessel and coding, MCA realised then they had a set of guidance notes called MGN280 that could not be legally enforced. MGN 280 is an amalgamation of all the colour codes into one document.

Brown Codes was dragged out of MGN 280 first and formatted as Work Boat Code ( many vessels have a dual code option) which has already gone through two rewrites and now on its third. It is first of codes to get legislation but the recent Work Boat 3 is just now under MCA review after going to Public Consolation after industry responses. The rest of MGN 280 is being formatted as another new code the Sport and Leisure Code- This is the drive to get it into legislation for our side of industry. Presently with industry professionals and MCA at review of each page. Even when that is done MCA have to send it to public consolation and then get it finalised for time in Parliament to pass legislation , Target date 2024 – bear in mind that is election year!!

More incidents involving ribs-
Osprey Rib Crash Scotland-July 2016- life changing injuries to passenger and a code certificate that was appalling allowing paying passengers to sit on tubes and not seating.

Rib crash in Buoy on river Thames July 2019- 8 injured and thrown in water in darkness, Vessel users believed they had more passengers than they did resulting in more rescue crews searching

Following the Osprey crash a group of industry and also MAIB and MCA sat down to review what operation documents were in place, At that time MGN 280 for coding of vessels ( guidance doc) then a High Speed voluntary code of practice from RYA and Passenger Boat Association(PBA) . ALL out of DATE! Images and instructions were nearly ten years old again. Other Charter groups (PCA Ltd) also formed new operational guidance docs for RIBs, This was formatted with the biggest RIB operator in UK and other operators from around the UK to improve safety from moment of booking through to the trip itself. During this time Shock Mitigation became a foremost update for many operators. From the MAIB run meeting with MCA a new document was requested from RYA and PBA- that took over 2 years to finish and publish HSPV code April 2019 Issue 3.

The industry has been working hard to put in place rules and regs but they come under the Dept of Transport and as you see it takes years despite the industry driving for more safety.

SOPs are now a standard approach for most operators with risk assessments covering all areas of operations. This was an area that was highlighted by marine experts at the recent trial.

Presently with insurance changes and new policies for operators introduced before this accident the industry has been improving and continues to do so. I know of plenty of reports to MCA about unsafe practices or unlicensed operations but the enforcement is poor. MCA state this accident was not as a result of failing to comply with the inspection code MGN 280 but highlighted the HSPV voluntary code failures

So do I support tightening of rules?> Yes 100% is my personal view and also think every use of any vessel should be licensed with training mandatory- yet this accident can hardly support that as fully licensed, high skilled skipper ( RNLI Coxswain trainer and RYA Advanced Power Boat Trainer).

Enforcement is a mega issue- lack of it, different rules for each area under local authorities or Ports, Categorised waters mean presently the MCA have little say or enforcement options as NOT AST SEA in definition terms. So MCA need to up their capability and start responding to information given to them and enforcement by ports and Harbour teams is no doubt going to be stepped up now after this accident

Sentencing is a matter for the criminal justice system. I heard the full facts on sentencing from the Judge and it was clear he was limited on custodial. There was also an issue that was not reported on a recent stated case March 2023- R V Ali- Stated:-

“You will appreciate that operating very close to prison capacity will have consequences for the conditions in which prisoners are held. More of them will be in crowded conditions while in custody, have reduced access to rehabilitative programmes, as well as being further away from home (affecting the ability for family visits). Prisoners held in police cells under Operation Safeguard will not have access to the full range of services normally offered in custody, including rehabilitative programmes.”

Other matters in the case also gave me a wider understanding of sentencing.

People have outlined other sentencing but this does not link into marine world and this accident. The judge gave very clear route to decisions for Jury and I guessed the outcome correctly from this. Point to prove in law are a big issue and must be proven to get a case home. I have spent years in and out of court processes so have a wide understanding of legal processes and evidence. Would I support changes to sentencing if this occurred again? I would only decide if I heard the facts, sorry media reporting was very unbalanced.
Things have not stayed as they were at the time of this accident and can honestly say have moved on a long way and we continue to strive for better processes, systems etc. Safety remains paramount for everyone. Will we stop accidents? Doubt it. look at our roads, heavily legislated and controlled and daily deaths around the UK occur, we don’t see this in the charter industry with thousands of trips each month. One accident involving passengers is one too many.

Since this accident I am aware of two other major accidents in marine industry of similar boats- Poole- 3rd May 2022- Fatal hitting a buoy at night, Totland Bay Sept 2022 a cruiser ran up rocky beach destroying boat at night and serious passenger injuries – Both ongoing criminal cases with police and MCA but both shown as private boating

Interesting and comprehensive. Don’t you think a simple low cost form of enforcement would be to go down the ‘secret shopper’ route for the MCA? They could just book a trip with a company under cover and make a report/ recommendations or enforcements based on that. All the paperwork in the world doesn’t make a company operate safely in their day to day business. The possibility of any trip being assessed could make the few companies letting the side down pull their trousers up. Don’t see how it would effectively be monitored otherwise.

[C2 RIBS]

Originally Posted by Iankristy

Interesting and comprehensive. Don’t you think a simple low cost form of enforcement would be to go down the ‘secret shopper’ route for the MCA? They could just book a trip with a company under cover and make a report/ recommendations or enforcements based on that. All the paperwork in the world doesn’t make a company operate safely in their day to day business. The possibility of any trip being assessed could make the few companies letting the side down pull their trousers up. Don’t see how it would effectively be monitored otherwise.

Yes agree, I am aware that the MCA booked a seat on Seadogz years ago and gave it a clean bill of health, so appears they do it, but that is with a single seat purchase say £40. I run charters and cheapest would be £550 up to £900!! There are now fewer operators offering single seat ticket sales, River Thames London do and a few around the coastal waters but in numbers they are a small %.

I know that reports go to MCA for enforcement but their enforcement is low

[Pikey Dave]

Originally Posted by C2 RIBS

Yes agree, I am aware that the MCA booked a seat on Seadogz years ago and gave it a clean bill of health, so appears they do it, but that is with a single seat purchase say £40. I run charters and cheapest would be £550 up to £900!! There are now fewer operators offering single seat ticket sales, River Thames London do and a few around the coastal waters but in numbers they are a small %.



I know that reports go to MCA for enforcement but their enforcement is low

Thanks for the comprehensive reply. In the face of poor enforcement by the MCA & the apparent reliance of industry self regulation (when has that ever worked in any industry? Banks spring to mind), maybe one of the few tools available is stiffer penalties. Personally I don’t think that a raft of new legislation is necessary. Ostensibly, there are plenty of existing laws/regulations that cover the safety of the public & employees. I’m still genuinely baffled how the skipper “got away with it” on this occasion. I’ve recently retired from 40years in mining & construction, & it truly staggers me how the people involved managed to walk out of court. I’ve known people jailed & companies fined millions for lesser “crimes”. That’s why I might be coming across like a dog with a bone on this. It’s beyond my comprehension.
Who actually brought the prosecution, was it the MCA or Police/CPS?

[C2 RIBS]

Originally Posted by Pikey Dave

Thanks for the comprehensive reply. In the face of poor enforcement by the MCA & the apparent reliance of industry self regulation (when has that ever worked in any industry? Banks spring to mind), maybe one of the few tools available is stiffer penalties. Personally I don’t think that a raft of new legislation is necessary. Ostensibly, there are plenty of existing laws/regulations that cover the safety of the public & employees. I’m still genuinely baffled how the skipper “got away with it” on this occasion. I’ve recently retired from 40years in mining & construction, & it truly staggers me how the people involved managed to walk out of court. I’ve known people jailed & companies fined millions for lesser “crimes”. That’s why I might be coming across like a dog with a bone on this. It’s beyond my comprehension.
Who actually brought the prosecution, was it the MCA or Police/CPS?

Agree self regulation only works if everyone signs up to it, standards will always be different with each company, some of the associations are doing all they can to get members to be gold standard rather than bronze etc.

The prosecution was Police driven inquiry into death with CPS decison to prosecute . MCA played a part at inquiry stage at police station interviews etc but marine experts were drafted into court to help as well , MCA were absent from court and not even called! a selection of new legislation is needed as you have identified your concerns of level of prosecution and sentencing.

The penalties were there, the level of penalties is decided on many factors and Judge made it clear the levels he set and why, very long and complicated.
Had persons involved fled country, offered no help, lied/covered up, shown no remorse etc etc then penalties could be different. Personally I see no reason to imprison anyone who is not a repeat offender or a danger to society, again that comes from my years outside this industry.

[Poly]

C2 - it appeared to me that with such a long period where the apparent collision course should have been obvious to the helm (as reported in the media) that a second crew member on board may have: been a second pair of eyes to spot the danger; reduced the risk that the helm was distracted by anything passengers were doing; provided the opportunity for a last minute intervention if the helm was incapacitated or something got in his face; meant that if skippers were regularly taking unnecessary risks or breaching SOPs the management would be more likely to be informed; meant if any other emergency happened there was someone with some training to assist. It’s always appeared to me that many of these type of boats push the manning levels to the limit (or beyond). Has the industry started to address that point?

Personally black boxes available for insurers doesn’t cut it for me. If I was responsible for the safety of boats driven like this I’d want to see (probably automated) analysis of every trip not just provide insurers with get out clauses or data to argue over next years premium with.

I think when people demand tougher sentences or new offences they should just bear in mind that any of us could end up involved in a fatal accident on our boat. We all like to think it won’t happen to us, but it might. And if it does prosecutors always have the benefit of 20:20 hindsight. Again, we like to believe we are very good, responsible and seaman like so if something did happen nobody could point the finger and it would just be bad luck. Presumably all the people nodding along saying you are safe and responsible and could never end up convicted for some hypothetical new “causing death by careless boating” charge… I assume when you drive to the boat you adhere perfectly to the Highway Code, never break the speed limit and have never had an “oh shit” moment when driving or only seen someone when it was a bit late and nobody else ever had to take avoiding action? New offences will be “used against” ordinary boaters who get things wrong as well as commercial operators.

[Pikey Dave]

Originally Posted by Poly

I think when people demand tougher sentences or new offences they should just bear in mind that any of us could end up involved in a fatal accident on our boat. We all like to think it won’t happen to us, but it might. And if it does prosecutors always have the benefit of 20:20 hindsight. Again, we like to believe we are very good, responsible and seaman like so if something did happen nobody could point the finger and it would just be bad luck. Presumably all the people nodding along saying you are safe and responsible and could never end up convicted for some hypothetical new “causing death by careless boating” charge… I assume when you drive to the boat you adhere perfectly to the Highway Code, never break the speed limit and have never had an “oh shit” moment when driving or only seen someone when it was a bit late and nobody else ever had to take avoiding action? New offences will be “used against” ordinary boaters who get things wrong as well as commercial operators.

Fair point, but most of us aren't taking fare paying passengers. As we have been reminded repeatedly, the skipper in this case was a highly trained/experienced/RNLI skipper. He wasn't some weekend boater out for a jolly with his mates/family. He was a "Professional" which makes his actions all the more horrifying, he should have known/performed better.

Originally Posted by Poly

New offences will be “used against” ordinary boaters who get things wrong as well as commercial operators.

And to be fair, why not? if you were driving & "got it wrong", you'd expect to suffer the consequences. I'd be the first to admit that I've had the odd driving offence on my license. I "got it wrong", got caught, paid the penalty. Given the lack of enforcement at sea, I'd assume that only the most serious offences would ever get anywhere anyway. TBH I've seen behaviour on the sea where the culprit needed locking up

[Iankristy]

Originally Posted by Poly

C2 - it appeared to me that with such a long period where the apparent collision course should have been obvious to the helm (as reported in the media) that a second crew member on board may have: been a second pair of eyes to spot the danger; reduced the risk that the helm was distracted by anything passengers were doing; provided the opportunity for a last minute intervention if the helm was incapacitated or something got in his face; meant that if skippers were regularly taking unnecessary risks or breaching SOPs the management would be more likely to be informed; meant if any other emergency happened there was someone with some training to assist. It’s always appeared to me that many of these type of boats push the manning levels to the limit (or beyond). Has the industry started to address that point?

Personally black boxes available for insurers doesn’t cut it for me. If I was responsible for the safety of boats driven like this I’d want to see (probably automated) analysis of every trip not just provide insurers with get out clauses or data to argue over next years premium with.

I think when people demand tougher sentences or new offences they should just bear in mind that any of us could end up involved in a fatal accident on our boat. We all like to think it won’t happen to us, but it might. And if it does prosecutors always have the benefit of 20:20 hindsight. Again, we like to believe we are very good, responsible and seaman like so if something did happen nobody could point the finger and it would just be bad luck. Presumably all the people nodding along saying you are safe and responsible and could never end up convicted for some hypothetical new “causing death by careless boating” charge… I assume when you drive to the boat you adhere perfectly to the Highway Code, never break the speed limit and have never had an “oh shit” moment when driving or only seen someone when it was a bit late and nobody else ever had to take avoiding action? New offences will be “used against” ordinary boaters who get things wrong as well as commercial operators.

Not sure the single handed operating fault holds much water. You could say the same for bus/ car/taxi/ train. Safe passage plan and proper vigilance would remove virtually all potential of this particular incident. Just doing your jobI basically. legislation filtering down to leisure users not a bad thing? We’ll all have seen things on the water that raised an eyebrow.
I would have multi quoted the answer but it seems I’m too basic to work out how to do it🤨

[Matt]

Originally Posted by Pikey Dave

....As we have been reminded repeatedly, the skipper in this case was a highly trained/experienced/RNLI skipper. He wasn't some weekend boater out for a jolly with his mates/family. He was a "Professional" which makes his actions all the more horrifying, he should have known/performed better.

Hmm. I wrote a long post a few days back about "professionals" and "experience" and so forth, but decided not to hit the button on it in the end.

But since you called out this statement, I'll reply. Through my historical involvement in the racing scene, I met many, many "highly experienced professionals". They all tell each other how great they are and when you try to flag a risk with them, the usual response was "That's the way I've always done it mate and I've never had a problem". I even include some RNLI crew in this - although in that case it's more "That's the way we do it in the RNLi" - yeah, but we're not on a fully loaded trent or even atlantic 21 with a full crew right now - so perhaps we should approach it using the vessel, people and resources we've got.....

Anyway - the issue I see is by having done it many times before, there is a lot of overconfidence in either the likelihood of something happening, or overconfidence in their ability to deal with it. The sea is a cruel mistress and the only motto I find works is the law of sod. Or in other words, always be humble, never stop asking yourself what could go wrong in any given situation and mitigate it before it starts escalating exponentially.

[Pikey Dave]

Originally Posted by Matt

Hmm. I wrote a long post a few days back about "professionals" and "experience" and so forth, but decided not to hit the button on it in the end.



But since you called out this statement, I'll reply. Through my historical involvement in the racing scene, I met many, many "highly experienced professionals". They all tell each other how great they are and when you try to flag a risk with them, the usual response was "That's the way I've always done it mate and I've never had a problem". I even include some RNLI crew in this - although in that case it's more "That's the way we do it in the RNLi" - yeah, but we're not on a fully loaded trent or even atlantic 21 with a full crew right now - so perhaps we should approach it using the vessel, people and resources we've got.....



Anyway - the issue I see is by having done it many times before, there is a lot of overconfidence in either the likelihood of something happening, or overconfidence in their ability to deal with it. The sea is a cruel mistress and the only motto I find works is the law of sod. Or in other words, always be humble, never stop asking yourself what could go wrong in any given situation and mitigate it before it starts escalating exponentially.

Yup, hubris & The Sea are poor bedfellows.

[Poly]

Originally Posted by Pikey Dave

Fair point, but most of us aren't taking fare paying passengers.

I agree it’s certainly an aggravating factor.

And to be fair, why not? if you were driving & "got it wrong", you'd expect to suffer the consequences.

i don’t have an objection so long as people calling for tougher sentencing realise that one day it could be them in the dock

Given the lack of enforcement at sea, I'd assume that only the most serious offences would ever get anywhere anyway. TBH I've seen behaviour on the sea where the culprit needed locking up

yes and it would certainly be patchy who got lucky and who didn’t (as to some extent it is even on the roads where every cop knows the basic rules and can easily get to you). It’s likely that only the ones with the worst consequences get prosecuted, rather than the equally bad errors where everyone got lucky - but the risk was the same and if deterrence is the objective nobody believes they will kill someone so they’ll never get penalised. Frankly putting the effort of revising the law into a greater police or harbour authority presence to either have a quiet word or pursue the existing offences would probably do more to change behaviour than new offences or harsher punishments nobody expects to see used.

Originally Posted by Iankristy

Not sure the single handed operating fault holds much water. You could say the same for bus/ car/taxi/ train.

trains make a big deal about the safety role of the guard. Not that long ago that bus drivers were separate from ticket collection etc. Generally none of those are operating a thrill ride experience (although I’ve had some terrifying taxi drivers!). Bus/car/taxi can generally pull over to the side and stop safely if there’s a problem. On a boat there is ALWAYS a foreseeable risk that the helm is incapacitated/ taken unwell / lands badly off a wave and injured themselves etc. In any other professional setting if you wrote down those circumstances and combined it with the equivalent of = adrift at sea or = careering at high speed at sea and you would really struggle to justify not having a second person who knew how to manage an emergency.

I think realistically a risk assessment should also cover forseeable distractions, like getting a text message, one of your passengers not sitting down, or trying to talk to you, or even a VHF call that sounds like a mayday etc. I personally would struggle to say they won’t happen and won’t distract you. If that is your policy I think it would be more convincing if the normal MO was two people on board to keep the other one honest!

We’ll all have seen things on the water that raised an eyebrow.

agreed. I’ve seen plenty of it on the roads too. It doesn’t always result in the sentences people feel it should even when the headlines describe total stupidity resulting in deaths.

[Nos4r2]

https://www.portsmouth.co.uk/news/cr...ource=hs_email

[C2 RIBS]

Originally Posted by Nos4r2

https://www.portsmouth.co.uk/news/cr...ource=hs_email

Full MAIB report here - release today 14/12/23

https://www.gov.uk/government/news/s...port-published

[C2 RIBS]

First attached did not work
https://assets.publishing.service.go...ogz-Report.pdf