Cranston Inquiry

Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is split between different geographical locations – HM Coastguard must ensure the effectiveness of measures in mitigating them (including the consequent loss of situational awareness) and regularly assess their effectiveness.

The Inquiry asked HM Coastguard to mitigate risks from network flexing in small boat operations. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete on an ongoing basis, with the Maritime and Coastguard Agency establishing an internal monitoring and reporting process (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that the service had reduced network flexing by increasing Dover staffing, dedicating watchkeepers to small boat crossings, and improving technical links for remote coordinators (Department for Transport response, Jul 2026). The department noted that arrangements remain under regular review rather than having a single end point (Department for Transport response, Jul 2026; Cabinet Office, Oct 2026).

HM Coastguard should seek, at pace, to invest in the technology required to support its ability to reconcile duplicate small boat incidents. Where this cannot be accommodated within the existing budgets of the Maritime and Coastguard Agency, the Department for Transport should ensure that further funding is made available for this purpose.

The Inquiry asked His Majesty's Coastguard to invest in duplicate small boat reconciliation technology. In October 2026, the Cabinet Office recorded the recommendation as complete, noting that work relies on an ongoing approach and that the Maritime and Coastguard Agency (MCA) had set up internal monitoring (Cabinet Office, Oct 2026). In July 2026, the Department for Transport (DfT) reported that the Coastguard had introduced unique caller identifiers, messaging software, and surveillance drones to reconcile incidents (Department for Transport response, Jul 2026). The department added that further technology was being explored through modernisation programmes and academic engagement, but it did not mention additional departmental funding (Department for Transport response, Jul 2026).

There should be regular assessments by HM Coastguard of the adequacy of the available assets and human resources to respond to both current and reasonably foreseeable levels of small boat activity. Where the forecast level of resourcing need cannot be delivered within budget, the position must be escalated rapidly to the Department for Transport.

The Inquiry asked His Majesty's Coastguard to regularly assess small boat response resources. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete under an ongoing approach, with the Maritime and Coastguard Agency establishing an internal process to monitor and verify progress (Cabinet Office, Oct 2026). The Department for Transport stated in July 2026 that operational measures were in place, including daily assessments of search and rescue asset availability, dynamic allocation of network staff, and biannual reviews of resourcing (Department for Transport response, Jul 2026). The department also detailed mechanisms to present risks to its sponsorship board quarterly and escalate worsening resource concerns directly when necessary (Department for Transport response, Jul 2026).

HM Coastguard should provide frequent training and retraining for their staff in aspects of search and rescue specific to small boats, one being the need to avoid normalcy bias, in particular, assumptions about exaggeration in calls from small boats.

The Inquiry asked His Majesty’s Coastguard (HMCG) to provide frequent small boat training. In October 2026, the Cabinet Office recorded that the recommendation had been marked as complete based on an ongoing approach, with the Maritime and Coastguard Agency (MCA) establishing internal monitoring and reporting processes (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that operational small boat training courses were introduced in 2021 and reviewed in 2025, but training to avoid normalcy bias or assumptions about call exaggeration was not mentioned in the sources (Department for Transport response, Jul 2026).

Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational response to a maritime search and rescue incident when the number of people requiring rescue exceeds the capability of the search and rescue units on scene.

The Inquiry recommended that maritime search and rescue responders formally adopt a mass triage procedure. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete under an ongoing approach subject to internal monitoring by the Maritime and Coastguard Agency (MCA) (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that His Majesty's Coastguard (HMCG) had incorporated the triage tool into its mass rescue operations plan and shared it with other search and rescue partners (Department for Transport response, Jul 2026). The department added that the tool had been adopted by the Royal National Lifeboat Institution (RNLI) and vessels contracted by the Border Security Command (BSC) (Department for Transport response, Jul 2026).

Those involved in maritime search and rescue should continue to undertake joint exercises on the application of the Mass Persons in the Water Triage procedure.

The Inquiry recommended continuing joint exercises on maritime mass water triage procedures. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete, noting that it relies on an ongoing approach and that the Maritime and Coastguard Agency has established an internal monitoring process (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that His Majesty's Coastguard participated in annual mass rescue live-play exercises from 2023 to 2025 and would test the triage tool again in October 2026 (Department for Transport response, Jul 2026).

The Department for Transport must consider recommending to the International Maritime Organization that it consider incorporating an in-water mass casualty triage tool within its policies and procedures.

The Inquiry asked the Department for Transport to recommend an international in-water triage tool. In October 2026, the Cabinet Office noted that the department had published updates against the recommendation in its interim response (Cabinet Office, Oct 2026). In that July 2026 response, the department stated that "the intent of this recommendation has been fulfilled" through existing guidance referenced by the International Maritime Organization (IMO), and confirmed it does not plan to make a separate recommendation (Department for Transport response, Jul 2026).

HM Coastguard should amend its existing policies to incorporate the need to provide more comprehensive advice about survivability to people in distress at sea.

The Inquiry asked HM Coastguard to incorporate more survivability advice into its policies. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete under an ongoing approach, with the Maritime and Coastguard Agency establishing an internal monitoring and verification process (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that standard operating procedures had been updated in May 2024 to align with international requirements and cover survivability factors, survival time predictions, hypothermia, and heat stress (Department for Transport response, Jul 2026).

HM Coastguard should examine whether it is using the most appropriate modelling for survivability in cold water. HM Coastguard should amend its existing policies to ensure that they consistently identify the key variables about which information is to be collected from people in the water. In the event that the number of people in the water makes information gathering more difficult, HM Coastguard's policies should prioritise the collection of the key variables.

The Inquiry asked HM Coastguard to review its cold water survivability modelling and information policies. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete based on an ongoing approach, with the Maritime and Coastguard Agency establishing internal monitoring and reporting (Cabinet Office, Oct 2026). Earlier, in July 2026, the Department for Transport stated that the model used adheres to international guidance and that standard operating procedures prioritise key information collected from people in the water (Department for Transport response, Jul 2026). The department added that ongoing collaboration with the United States Coast Guard is sharing immersion data to assess whether international guidance should be updated (Department for Transport response, Jul 2026).

HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development or deployment of equipment and techniques to assist in search and rescue operations.

The Inquiry asked HM Coastguard to liaise with partners on rescue equipment and techniques. The Cabinet Office reported in an October 2026 update that the recommendation had been marked as complete on an ongoing basis, adding that the Maritime and Coastguard Agency had established an internal process to monitor and verify progress (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that the coastguard was holding monthly meetings with the Royal National Lifeboat Institution alongside bilateral discussions and multilateral forums with international partners to share operational lessons (Department for Transport response, Jul 2026).

For so long as the current arrangements in relation to search and rescue in the English Channel remain in place, the roles and responsibilities of HM Coastguard and Border Force should be set out in a memorandum of understanding.

The Inquiry recommended a memorandum of understanding between HM Coastguard and Border Force. In October 2026, the Cabinet Office reported that the Department for Transport is working to put in place a memorandum of understanding setting out roles and responsibilities (Cabinet Office, Oct 2026). The department previously stated in July 2026 that it was working with Border Security Command within the Home Office on the agreement (Department for Transport response, Jul 2026). Both sources note that an update will be provided in the department's final response to the Inquiry (Department for Transport response, Jul 2026; Cabinet Office, Oct 2026).

HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English Channel and elsewhere.

The Inquiry asked His Majesty's Coastguard to schedule regular joint maritime training exercises. In October 2026, the Cabinet Office reported that the recommendation had been marked as complete under an ongoing approach, with the Maritime and Coastguard Agency (MCA) establishing internal monitoring and reporting for its operational responsibilities (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that regular liaison and annual live exercises with partner organisations were established, with two yearly table-top exercises instituted and the next live exercise planned for October 2026 (Department for Transport response, Jul 2026).

HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, and public and external affairs.

The Inquiry asked HM Coastguard to develop a detailed mass rescue operation plan. In October 2026, the Cabinet Office reported that this recommendation has been marked as complete under an ongoing approach, with the Maritime and Coastguard Agency (MCA) establishing internal processes to monitor and verify progress (Cabinet Office, Oct 2026). The Department for Transport had stated in July 2026 that the plan was refreshed in April 2026 to align with international guidance, covering incident command and stakeholder roles, though medical, law enforcement, and public affairs aspects were not mentioned (Department for Transport response, Jul 2026).

HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold for making a referral on a potential breach by a vessel of the duty to render assistance, the information to be communicated and how the numbers of referrals are to be annually reported.

The Inquiry recommended establishing a protocol for referring potential breaches of the duty to assist. In October 2026, the Cabinet Office reported that the recommendation was marked as complete under an ongoing approach, with the Maritime and Coastguard Agency establishing an internal monitoring and reporting process (Cabinet Office, Oct 2026). Earlier, in July 2026, the Department for Transport stated that His Majesty's Coastguard updated its operating procedures in October 2023 to refer vessels that ignore distress broadcasts to regulatory investigators (Department for Transport response, Jul 2026). The department added that it would develop a process to record referrals and collect data, though arrangements for annual reporting were not detailed (Department for Transport response, Jul 2026).

The Marine Accident Investigation Branch should make publicly available on its website, as soon as possible after they are received, the details of implementation measures taken by those to whom a recommendation is addressed, or an explanation for not taking implementing measures, unless there are strong reasons not to do so. If needs be, the 2012 Regulations should be amended accordingly.

The Inquiry asked the Marine Accident Investigation Branch (MAIB) to publish recommendation responses online. In October 2026, the Cabinet Office reported that the branch anticipates implementing the recommendation by May 2027, noting that regulatory change is not expected to be required (Cabinet Office, Oct 2026). In July 2026, the Department for Transport stated that both it and the branch agreed implementation would improve visibility and transparency regarding actions taken in response to recommendations (Department for Transport response, Jul 2026).