Emily Lewis

UKHMA - PO BOX 312, MORPETH, NE61 9GN Tel: (Executive officer & Secretary); (Membership & Accounts) Email:

The Harbour Masters’ Association of the United Kingdom, the Channel Islands and the Isle of Man

PO Box 312 Morpeth NE61 9GN

08/01/2025 HMAC Henry Charles Coroner’s Office Castle Hill Winchester Hampshire SO23 8UL

By email:

Response to Regulation 28 Report to Prevent Future Deaths following inquest into the death of Emily Jane Lewis

Introduction:
1. I refer to your Report to Prevent Future Deaths (the “Report”) dated 15th November 2024 concerning the death of Emily Jane Lewis who died on 22nd August 2020.

2. I am replying as the President of the UK Harbour Masters’ Association (“UKHMA”).

3. At the outset of this response, I would like to express my sincere condolences to the family of Emily Jane Lewis. The UKHMA was saddened to learn of the circumstances of the incident on 22nd August
2020. The UKHMA has engaged with a number of stakeholders following the incident and has continued to do so following the conclusion of the inquest.

The Role of UKHMA:
4. The UKHMA was formed in 1993 and is a professional body consisting of harbour masters, port marine operations officers, harbour managers, commercial bodies that serve the port sector, and other appropriate personnel and organisations. It has approximately 500 members.

5. The UKHMA consists of eight regional constituencies that cover all mainland and island ports in England, Wales, Scotland, Northern Ireland, the Channel Islands and the Isle of Man and includes the UK Crown dependencies.

6. The principal harbour master, or any person who in the normal course of their duties is expected to deputise for the principal harbour master, of any statutory port or harbour (“SHA”) in the UK, Channel Islands and the Isle of Man is eligible to become a Full Member of the UKHMA.

UKHMA - PO BOX 312, MORPETH, NE61 9GN Tel: (Executive officer & Secretary); (Membership & Accounts) Email:

7. There is provision also for other senior port marine officers, and any person interested in upholding the objectives of the Association, to become Associate or Affiliate Members. At the start of 2024, there were approximately 500 Members of the UKHMA.

8. The objectives of UKHMA are as follows:

a. to exercise and promote the safe and efficient conduct of marine operations in ports, in accordance with the Port Marine Safety Code and the Guide to Good Practice on Port Marine Operations (or any replacement thereof);
b. to promote the interests and professional competence of Harbour Masters in the United Kingdom and Crown Dependencies;
c. to encourage and facilitate the qualification, certification and continuing professional development of Harbour Masters in the United Kingdom and Crown Dependencies;
d. to represent by way of professional advice and support the views of Harbour Masters to the UK Government and devolved administrations, to organisations representative of port authorities, and to other persons within the United Kingdom and Crown Dependencies and elsewhere concerned with marine operations, both within and near port waters;
e. to share experiences, knowledge, information and best practice among Harbour Masters;
f. to affiliate to such other bodies as the Council may think appropriate.

9. Given the UKHMA’s expertise in the shipping and port industry throughout the UK, it participates in many inter-industry forums, working groups and consultations, including those initiated by the Maritime and Coastguard Agency (“MCA”), Department for Transport (“DfT”), Marine Accident Investigation Branch (“MAIB”) and regional governmental bodies, etc.

10. As the UKHMA is an unincorporated representative body, it has no statutory powers or regulatory functions. The UKHMA is principally a professional members Association and represents the views and interests of UK Harbour Masters. It does not represent the statutory harbour authority entities for which the Harbour Masters work.

The Role of Harbour Masters:
11. The Harbour Master is responsible for overseeing the safe navigation and use of the harbour among other statutory requirements such as Oil Spill prevention & response. The role will vary depending on the size of the harbour and the type of vessels using it.

12. Currently, there are no mandatory qualifications to hold the position of Harbour Master. It is a decision for the port, or more specifically the port’s Duty Holders, to satisfy themselves that the Harbour Master is suitably qualified to carry out their responsibilities under the terms of the Port Marine Safety Code (“PMSC”). In 2012 (and reviewed in 2019), National Occupational Standards for Harbour Masters (“NOS”) were published which set out the basic knowledge, understanding and experience required for Harbour Masters to comply with the PMSC. NOS is overseen by the industry body, Port Skills and Safety.

13. In 2012, UKHMA introduced the non-mandatory Harbour Master Certificate, which is recognised by the MCA , closely reflecting the content of the NOS for Harbour Masters.

UKHMA - PO BOX 312, MORPETH, NE61 9GN Tel: (Executive officer & Secretary); (Membership & Accounts) Email:

The Circumstances of the Death and Matters of Concern:
14. I have carefully read the Report and have noted in particular that you heard evidence of multiple issues which revealed matters giving risk to concern.

15. In particular, I have noted the specific concerns listed a. to f. in box 5 of the Report.

16. It is not immediately clear to me specifically which concerns resulted in the decision to issue the Report to UKHMA but it may assist to outline the involvement UKHMA has had with stakeholders in relation to issues arising from the incident on 22nd August 2020 and the action which UKHMA considers it is in a position to take.

17. MAIB reported on 14th December 2023 and its report contained a number of recommendations. UKHMA received one recommendation (recommendation 2023/14). The recommendation was issued to the British Ports Association (“BPA”), UKHMA and the UK Major Ports Group (“UKMPG”). The wording of the recommendation was to, “Contribute to the development of guidance for their members clarifying the requirements and best practices for the oversight of small commercial craft operating in their areas of responsibility”. This recommendation stemmed from the conclusion at
3.1.15 of the report which stated “The framework for the licensing and oversight of commercially operated craft can be complex and subject to interpretation and would benefit from further guidance”, which in turn was a consequence of the report’s findings at 2.9.5 relating to the framework for the licensing of commercially operated craft and the finding that harbour authorities would benefit from further guidance on how to best regulate and oversee commercial high-speed operators in their area of responsibility.

18. In considering the context of this recommendation, UKHMA considers it may be important for the Coroner to understand the following limitations in respect of the powers of Statutory Harbour Authorities (“SHAs”) and the Harbour Masters they employ:

a. Each SHA has different, bespoke, legal powers relating to their port / harbour;
b. It can be difficult / take a long time to make changes to each SHAs regulations (Harbour Orders to amend / obtain statutory powers are currently taking in the region of 4 years for the Marine Management Organisation to determine and unless an SHA has suitable powers of General Direction to utilise, byelaw applications to the Department for Transport can also take years to determine);
c. Harbour Master’s themselves (as opposed to the SHA entities they work for) usually have very limited powers to issue new regulations (the main power being the power of ‘special direction’ to issue a direction to a particular vessel in particular circumstances – i.e. to a particular vessel to move from a berth, or to proceed to a particular place within the port etc.).

19. During the period up to the issue of the MAIB’s final report and recommendations, the UKHMA contributed to the investigation as a key consultee. A number of on-line meetings between the MAIB and the Incident report consultees were held to discuss both the report’s findings and the MAIB’s recommendations.

UKHMA - PO BOX 312, MORPETH, NE61 9GN Tel: (Executive officer & Secretary); (Membership & Accounts) Email:

20. The UKHMA’s formal response to recommendation 2023/14 was sent to the MAIB on 12th January 2024 and was as follows, “The UK Harbour Masters’ Association (UKHMA) will propose to the Maritime and Coastguard Agency (MCA) that guidance regarding small commercial craft operating within harbour areas is developed as part of the review of the Port Marine Safety Code Guide to Good Practice (GTGP). UKHMA are participating in the current review of the GTGP and will contribute to the development of such guidance, which will be published by the MCA as the appropriate regulatory and enforcement body”.

21. UKHMA’s response to the MAIB additionally said “UKHMA will make the above proposal for inclusion in the agenda for the next meeting of the GTGP working group on 31st January 2024. The completion date for the review of the GTGP is currently expected to be approximately quarter 3 of 2024”.

22. As a professional members association, the UKHMA communicated and engaged with its membership regarding the interim MAIB report, the final report and its findings via its internal email porthole and eNews letters, allowing for feedback and response to the UKHMA Officers and Council.

23. The MAIB report, and the issues and recommendations arising from it, were brought to the PMSC steering group where the UKHMA contributed to discussions around how the learnings could be considered for inclusion in the new edition of the PMSC and the GTGP.

24. There has also continued to be engagement by UKHMA with the MAIB and MCA regarding the certification, operation and enforcement of MCA Coded craft and passenger vessels within SHAs.

25. During the 2024 UKHMA Autumn conference (November 2024, London) an expert panel session was held to discuss and consider the Seadogz report outcomes and future best practice of Coded craft within SHAs. The panel included senior officers of the MCA, MAIB and the UKHMA. Conclusion:
26. On behalf of UKHMA, I am grateful for you identifying the UKHMA as an organisation who may be able to assist in relation to the matters set out within your report.

27. I hope that this response assists you in understanding the UKHMA’s role and the action it has and will continue to take in relation to the safety of marine operations in ports and harbours.

28. Should you require any further information, please do not hesitate to contact me.

Dear Mr Charles, Thank you for your communication of 18th November 2024. I am writing in response to your various points raised. However, prior to doing so, it may be worthwhile providing some context about the RYA and, in particular, the extent of our authority. The RYA is the national governing body for sailing and multiple other forms of boating in the UK. We provide training courses for both recreational boaters and masters of small commercial vessels, with RYA qualifications for the latter being formally recognised for commercial use by the UK’s maritime regulator, the Maritime & Coastguard Agency (MCA). RYA Training Schemes were first started in 1970, and now extend to 58 countries, with our training delivered through a network of 2,300 independently owned and operated “RYA Training Centres.” Whilst the RYA has the authority to determine the standards for its courses and for the conditions under which RYA Recognised Training Centres operate, it does not have the authority to determine or enforce standards for operations within the small commercial vessel sector (and indeed the Small High Speed Passenger Vessel sector). This responsibility falls of course to the MCA as the UK maritime regulator, or in some circumstances to the relevant local port or local authority. That said, the RYA has always had a primary focus on safety and for that reason we take a proactive approach to influencing change where we can, either through behaviour of the boating public and commercial operators, or through work with organisations such as the MAIB and MCA, and others. This can be seen for example in our creation of the “Small High Speed Passenger Vessel Voluntary Code of Practice” 15 years ago, now in its 3rd edition. I have consulted with colleagues in both the RYA’s Training and Technical departments with regards the concerns you have expressed. Their responses are as follows:

a) Each port or local authority has the ability to regulate the use of small commercial vessels within their jurisdiction. Whilst there are some port and local authorities which will no doubt have the expertise and resource to deal with such matters, there are others who may not, and therefore regulating on a port by port basis may lead to inconsistencies between the standards adopted.

The MCA regulates commercial vessels used “at sea”, i.e outside of categorised waters which are often within the jurisdiction of port or local authorities, however this can result in uncertainty when an MCA coded vessel (such as Seadogz) is used within categorised waters.

The RYA notes the issue of inconsistent regulation applies to all commercial vessel operations, and not just to those used for high-speed experience rides.

Accordingly, the RYA believes there is an opportunity to review the position and either align the requirements of various harbour or local authorities in their treatment of commercial craft, or for the MCA to consider the issue on a national basis, however the RYA does not believe that it would be appropriate for the MCA’s “Sport or Pleasure Vessel Code” which is currently out for public consultation, to be applied on a blanket basis to all small commercial vessels only used within categorised waters. The RYA recommends that any uniform standard must be proportionate and take into account the nature of vessels and risk profile of operating within categorised waters.

b) The RYA notes that a draft “Sport and Pleasure Vessel Code” was recently released for consultation, and it is our understanding that the finalised version of the code will follow in
2025. Whilst there is certainly benefit in promoting safety and key messages within the Small High Speed Passenger Vessel sector (direct to the operators of those craft) in the interim, we do not believe it is feasible to develop and implement temporary measures without the risk of causing confusion for operators.

c) The RYA would support a revision to the ISO Standard. However, this should not be seen as a solution for existing craft. Retrospective steps for existing craft would undoubtedly be unworkable, unviable and are likely to have unintended consequences. Operators of existing craft should instead be educated to have safety management systems, conduct appropriate risk assessments and take the necessary steps to mitigate against any identified risks.

d) The RYA supports the notion of a review of seat and handrail design for new craft within the Small High Speed Passenger Vessel sector. However, we believe that addressing this issue with existing craft is best done through better education of operators and skippers on safety management systems, and the implementation of effective risk assessments, supported by appropriate steps to mitigate against identified risks. Examples would include measures such as limiting speeds when passengers occupy certain seats, or perhaps limiting operations to

certain sea states. The RYA is aware of an outstanding recommendation from the MAIB to the MCA to “Conduct an anthropometric assessment of the design and operational requirements for small high-speed passenger craft safety to develop a framework for assuring the protection of passengers and crew provided by the craft with respect to whole-body vibration and sudden decelerations in the event of a horizontal impact.”. The RYA believes this study, and its subsequent implementation into the codes of practice by the MCA, will address your concerns in this area, however, as highlighted in point a) further consideration is needed around the applicability of the current and any future code requirement to vessels operating exclusively in categorised waters.

e) Technology such as AIS is likely to increase the visibility of commercial vessels and may allow vessel tracks to be analysed more clearly after an incident, however while remote oversight may have some deterrent effect, the RYA questions the benefit of such technology for proactive monitoring on the basis that few harbour authorities will have the resource to proactively monitor all movements of Small Commercial High Speed Passenger vessels, while identifying speed and course may not allow an informed decision to be made remotely as to the safety implication of that behaviour in respect of a particular vessel, or enable intervention unless the vessel is operating in breach of legislation. Accordingly, the RYA does not believe that the use of technology is a substitute for appropriate training and safety management systems. The RYA does not believe that AIS is suitable for all vessels on a blanket basis.

f) The RYA fully supports the timely implementation of MAIB recommendations. We achieve this ourselves by maintaining a close working relationship with the MAIB and, where possible, by being involved in the recommendations consultation process. I note that the current MAIB recommendation for a review by the RYA of the existing “Small High Speed Passenger Vessel Voluntary Code of Practice” has been delayed due to the need to await the outcome of the MCA legislation for this sector of the industry. We felt, and the MAIB agreed, that releasing an amended version of the Voluntary Code of Practice at this point, where there was real risk of it either conflicting with or leaving unintended gaps, ran the risk of creating confusion within the sector and potentially undermining the “revised “Sport and Pleasure Code,” which we anticipate will address the majority of these issues. We envisage releasing a revised edition of the Voluntary Code of Practice soon after we have sight of the finalised MCA Sport and Pleasure Vessel Code. As an aside, it is noted that throughout your communication to us you reference “RIB craft” in relation to high-speed experience rides. It is respectfully suggested that it may be more appropriate to refer to these vessels as “small high speed passenger vessels”. Whilst it is true that many such experience rides do indeed utilise craft with an inflatable collar, not all of them do. Further, with the rapid evolution vessel design, it is entirely possible that this sector may move towards craft which do not have inflatable collars in the future. Indeed, in many parts of the world that is already the case. In order to ensure that any positive steps to come from your recommendations can be applied universally across the relevant craft, it will be important to ensure that appropriate terminology and definitions of craft

are used. This will avoid inadvertently ruling certain craft “out of scope”, simply for their lack of an inflatable collar. The risks on small high speed passenger vessels remain the same, whether they happen to be a RIB or not. Please do not hesitate to contact me should you require further clarification.

Dear Henry,

Subject: Regulation 28: Report to Prevent Future Deaths

I am grateful for your careful consideration of the circumstances of the tragic accident involving Emily Jane Lewis and highlighting the opportunities for improvement in safety in your Regulation 28 Report to Prevent Future Deaths of 15 November.

I would like to take this opportunity to reassure you that the work currently being undertaken by the Maritime Coastguard Agency (MCA) to replace the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280(M) (Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) is a priority of mine and we are working hard to bring forward new legislation and an updated Code of Practice for Small Vessels in Commercial Use for Sport or Pleasure (the “Sport or Pleasure Vessel Code”) as soon as practical, in line with the required consultation and Parliamentary processes.

To this end, a draft new Statutory Instrument and draft Sport or Pleasure Vessel Code was published for a 12-week public consultation running from 4 December 2024 until 25 February 2025. It should be noted that any interim measures that could be considered to manage risks of high-speed RIB experience rides would not be able to be implemented any sooner than the revised Sport or Pleasure Vessel Code would come into effect.

There have been significant developments in the draft Sport or Pleasure Vessel Code to address concerns you have raised, such as improved requirements for seating in vessels undertaking this type of operation, greater use of vessel Automatic Identification Systems (AIS) and a new mandatory requirement for owners and operators to implement a safety management system.

In response to the MAIB recommendations raised, I have tasked the MCA to begin the procurement process to commission an anthropometric assessment of the design and operational requirements for small high-speed passenger craft safety and the protection of passengers and crew provided by the craft with respect to whole-body vibration and sudden decelerations in the event of a horizontal impact.

This assessment will also consider, among other things; the full anthropometric range of passengers and crew, the operational profile of the vessels, including the range of speeds, as well as crash protection and general protection of the seating arrangements including the design and use of handholds and restraints.

The outputs from this assessment are expected in late spring/early summer 2026 and will be incorporated, as appropriate, into the next version of the Sport or Pleasure Vessel Code. The MCA will also use the information and data gathered to provide updated guidance to the wider pleasure vessel sector on passenger safety information.

As well as the proactive steps to improve small commercial vessel safety with the amendments made in the draft Sport or Pleasure Vessel Code, the MCA will continue to work to ensure that owners and operators take seriously their responsibilities for ensuring the safety of those onboard their vessels.

Dear Mr Charles Subject: Regulation 28: Report to Prevent Future Deaths I am writing to you in response to your Regulation 28 Report to Prevent Future Deaths following the tragic accident involving Emily Jane Lewis. We received the MAIB recommendations on 17 November 2023 ahead of the final report being published on 14 December 2023. By that time, there had already been significant developments in the draft of the Sport or Pleasure Vessel Code to address concerns you have raised, such as improved requirements for seating in vessels undertaking this type of operation, greater use of vessel Automatic Identification Systems (AIS) and a new mandatory requirement for owners and operators to implement a safety management system. Staff at MCA have prioritised work to replace the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280(M) (Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards). We are focussing on bringing forward new legislation and an updated Code of Practice for Small Vessels in Commercial Use for Sport or Pleasure (the “Sport or Pleasure Vessel Code”) as soon as practical, in line with the required consultation and Parliamentary processes. The findings and recommendations of the MAIB Investigation Report have informed the development of this draft Code, and we can report that the Parliamentary process of that legislation

is currently at the midpoint of a 12-week public consultation running from 4 December 2024 until 25 February 2025. It should be noted however, that any interim measures that could be considered to manage risks of high-speed RIB experience rides would not be able to be implemented any sooner than the revised Sport or Pleasure Vessel Code would come into effect. Furthermore, the MCA has begun the procurement process to commission an anthropometric assessment of the design and operational requirements for small high-speed passenger craft safety and the protection of passengers and crew provided by the craft with respect to whole-body vibration and sudden decelerations in the event of a horizontal impact. This will require, among other things; assessment of the full anthropometric range of passengers and crew, the operational profile of the vessels, including the range of speeds, as well as crash protection and general protection of the seating arrangements including the design and use of handholds and restraints This research project will commence by April 2025, and then the final report is likely to be available in late spring/early summer 2026. The outputs of this report will be incorporated, as appropriate, into the next version of the Sport or Pleasure Vessel Code. We will also use the information and data gathered to provide updated guidance to the wider pleasure vessel sector on passenger safety information. As well as the proactive steps to improve small commercial vessel safety with the amendments made in the draft Sport or Pleasure Vessel Code we will continue to work to ensure that owners and operators take seriously their responsibilities for ensuring the safety of those onboard their vessels. I remain at your disposal.

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INQUEST INTO THE DEATH OF EMILY JANE LEWIS ________________________________________________

I , Director of Red Bay Boats Limited, write this statement, in response to the Prevention of Future Deaths Report, made by the Coroner of Hampshire, Portsmouth and Southampton, following an inquest which took place on 31 October 2024.

Background

1. On 31 October 2024, the inquest into the death of Ms Lewis concluded and the Coroner gave the following narrative conclusion:

a. On 22 August 2020 the Deceased died at Southampton General Hospital, Temona Road, Southampton, Hampshire.

b. On the morning of 22 August 2022, Ms Lewis had sustained upper abdominal injuries when the RIB Seadogz, on which she was a passenger, collided with a buoy, projecting her forward into the extended handhold in front of her, causing fatal injuries: the Deceased’s liver was compressed against her spinal column leading to transection, along with contusion of the pancreas.

2. We also received a Regulation 28: Prevention of Future Deaths (PFD) Report, which we understand was sent to several parties following the inquest. The Report related to the following concerns raised by the Coroner:

a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensible framework for the use of RIB craft on high speed

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2 experience rides, including crewing levels, manoeuvres, craft standards and risk assessments;

b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides;

c. Whether the existing BS EN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft;

d. The need for consideration of seat and handrail design: as well as the injuries sustained by Emily Lewis, I note the MAIB’s concerns about handholds for jockey seats;

e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified;

f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved.

3. Firstly, everyone at Red Bay Boats Limited, the owners and employees, extend our heartfelt condolences to the friends and family of Ms Emily Jane Lewis during this difficult time.

4. We would like to extend our gratitude to the Coroner for reaching out to us with the concerns raised and affording us with the opportunity to respond. We greatly appreciate the chance to address these matters.

5. Red Bay Boats Limited has been a trusted leader in the boat building industry for 47 years. Throughout this extensive history, we are proud to report that we have not been aware of any injuries or fatalities caused by our vessels. Our

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3 commitment to safety, quality craftsmanship, and innovation continues to guide every aspect of our operations.

6. Safety at sea is at the core of our ethos in boat building. Many of our employees are also proud volunteers for the RNLI, further demonstrating our commitment to maritime safety.

7. At the time that the Seadogz vessel was built in 2012, it was designed and constructed for commercial use and was approved in accordance with the Marine Guidance Note (MGN) 280 (M) Small Vessels in Commercial Use for Sport or Pleasure, Workboats and Pilot Boats – Alternative Construction Standards and its annex the Small Commercial Vessel and Pilot Boat Code (‘SCV Code’) and was built to comply with the requirements laid down in the Recreational Craft Directive (‘RCD’) design category B. At all times, the Seadogz was built with the expectation that it would be operated by two persons, a helmsman and a navigator.

8. We acknowledge the concerns raised by the MAIB Report that the SCV Code does not make any reference to the number of seats required on a RIB, what constitutes suitable seating, nor any specific considerations relating to crash protection characteristics of the seating arrangement in the event of a high- speed impact and gives no generic requirements for forward visibility. We also note that there appears to be inconsistency between the ‘Passenger Safety On Small Commercial High-Speed Craft & Experience Rides: A Voluntary Code of Practice’ and the MAIB Report on whether or not a RIB should have an aft helm.

9. The Company is also concerned that the design of Seadogz is a design replicated by a number of those in the boat building industry and that Marine Guidance Note 436 does not provide any guidance on load factors on the design of the seating. That is, to what ‘crash’ or load standard should seats be tested to?

10. Sadly, the Operations Manager for Red Bay Boats Limited, who was responsible for design, engineering, finance, and human resources, passed

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4 away unexpectedly in Febuary 2024. However, action had already been taken before his untimely death, and these efforts have continued since. The following steps have been implemented:

a. Review and Update of Owner’s Manuals:

i. All owner’s manuals for vessels built by Red Bay have been reviewed and updated to confirm compliance with ISO 10240:2022. The manuals are now fully customised and tailored to the individual customer and vessel.

b. External Naval Architect Audit:

i. McCollum Marine, an external naval architect, has been instructed to conduct a comprehensive audit of all Red Bay-built vessels. The final report is expected by the end of January 2025. The audit will cover, but is not limited to, drawings, sketches, calculations, scantlings, and stability tests. Any recommendations from the external architects will be acted upon as soon as reasonably practicable.

c. Seating and Handhold Testing:

i. A testing company has been commissioned to assess the designs of the seating and handholds on Red Bay vessels. The loads on the pod seats will be tested to determine their endurance in the event of a collision. Test results are expected by the end of February 2025. These results will help set load factor and stress conditions on future vessels, influencing the design of new seating, which will be commissioned by the end of May 2025 and re-tested thereafter.

d. Compliance with Marine Guidance Note 436:

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i. All Red Bay vessels are in compliance with Marine Guidance Note 436.

e. Commissioning of Passenger RIBs:

i. Red Bay has not accepted any commissions for thrill-seeking passenger RIBs in the past three years and is unlikely to do so until the Marine and Coastguard Agency (MCA) updates its regulations in this area.

f. Monitoring Legislation Changes:

i. Red Bay is closely monitoring the MCA’s anthropometric study and any review of ‘The Sport & Pleasure Vessel Code’ to ensure full compliance with future legislative changes.

g. Recruitment of Compliance Officer:

i. Red Bay is in the process of recruiting a compliance officer to maintain management systems for all policies related to the International Organisation for Standardisation (ISO), MCA, and to keep abreast of any information or guidance from the Marine Accident Investigation Branch (MAIB).

h. Request for MAIB Report:

i. Red Bay has requested the STC report from the MAIB, including its raw data, to assist its experts in understanding the concerns raised in the report and to inform Red Bay's response. These results are yet to be received.

Actions

11. We have taken the Coroner’s concerns as an opportunity for Red Bay to

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6 systematically work through the range of boats to ensure accuracy and compliance and improve quality standards.

12. During the time of the MAIB investigation, the late Operations Manager became aware that the owner’s manual was not as specific as it could be. In response, he immediately assigned the task to oversee a project to bring all manuals up to the required standard.

13. To ensure thoroughness, and as stated above, we have appointed external naval architects, McCollum Marine, to review all of our documentation to aid in ensuring our Owner’s Manuals are fully compliant. This process is expected to be completed by the end of January 2025.

14. The general aim is to implement a detailed report for each vessel that clearly demonstrates compliance to standards and conformity. From this basis, we then intend to review our owner’s manuals, and indeed, update and recertify our business to the quality standard ISO90001.

15. We are keen to meet the WorkBoat Code 3.

16. To enhance our compliance and documentation efforts for this project, ensuring full regulatory and safety adherence, the following actions have been suggested:

a. ISO Scantling Requirements:

i. This will include analysing all current hulls against ISO scantling requirements in preparation for Workboat 3 certification.

ii. Implementing detailed drawings of layups, structural elements and bonding materials.

b. Superstructure Requirements for Cabin RIBs:

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i. Specifying layup requirements for structures

ii. Perform self-righting calculations for all cabin RIBs.

c. Stability and Flotation Compliance:

i. Assess compliance with the following standards:

1. ISO 6185-3:2024 (boats <8m, motor power ≥15 kW).

2. ISO 6185-4 (boats with hull lengths between 8m and 24m, motor power ≥15 kW).

3. ISO 12217-1: Stability and buoyancy assessments for small craft with hull lengths ≥6m (non-sailing boats).

d. Transom Analysis:

i. Ensure compliance with ISO 12215-5 and ISO 12215-6, verifying transoms can withstand:

ii. Maximum stresses from engine power and torque .
iii. Engine mass under normal operational conditions.

e. Maximum Power Determination:

i. Establish the maximum allowable power for each model according to ISO 11592.

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f. Manoeuvring Speed Testing:

i. We will test and verify the maximum manoeuvring speed for each model as per ISO 6185-4.

g. Field of Vision Compliance:

i. We will include field of vision assessments as per ISO 11591.

Seating design improvements

17. Our objective is to test our existing pod seating against the International Maritime Organisation HSC 2000 Standards and to seek recommendations for any improvements.

18. We intend to model the current pod seat (000-0051) in accordance with the load cases prescribed in the HSC 2000 Standards Annex 10. Then, to separately assess handhold strength as per the requirements outlined in ISO 15085, Section 9.3.

19. We have instructed Scot Seats, a sector specialist, who have confirmed they have received our seats at their premises in Scotland and will be testing them early in 2025. A copy of the testing protocol provided by Scot Seats which is currently being used to carry out tests on their own range of Shock Mitigation Jockey Seats to meet the HSC 2000 Standards, is enclosed at Exhibit RB/1.

20. Should a customer approach us now, we would recommend the installation of Scot Seats, as they provide better safety and comfort for both passengers and crew. This recommendation aligns with the voluntary guidance currently in place. If customers are unable to afford suspension seats, we will ensure that the seats we provide have been rigorously tested to meet safety standards. Our seats will be presented as the next best option, with a clear proviso that they

are to be used under certain conditions and within specific provisions. Conclusion
21. We would like to again acknowledge the tragic loss of Emily Jane Lewis, and extend our heartfelt condolences to her friends and family. Red Bay Boats remains committed to working alongside regulators and industry experts to enhance the safety of passenger vessels.
22. The law currently allows individuals with minimal experience to operate sea safari craft, but we firmly believe that such operations should be more regulated. Specifically, we feel that sea safari craft should not need to exceed 25 knots.
23. We have made a decision to not accept any commissions in the thrill-seeking market at this time.
24. At Red Bay Boats Limited, our priority is to ensure that our vessels are as safe as possible. We strongly believe that the industry should be better regulated, and that there should always be two people in command of a craft to enhance safety and reduce risks. 9 Mr Thomas McLaughlin Director of R imited Signed: Dated: r, I o,/2o2.s-'