Prevention of Future Deaths report 2014-0357

Canal &
= <m River Trust

Keeping people, nature & history connected

Your Ref [i

29" September 2014

Mr 1S Smith LL.B, Hon DUniv
HM Senior Coroner
Coroner’s Chambers

547 Hartshill Road

Stoke on Trent H.M
ST4 6HF .M.C. JS
-{ ALT 2014
STOKE-ON-TRENT AND
Dear Mr Smith NORTN STAFFORDSHIRE

Re: Michael HOLGATE (deceased)
Date of Birth: 03/06/1955

Date of Death: 20/05/2014

Thank you for your letter of the 4" August 2014 regarding the inquest into the death of Mr Michael
Holgate. On behalf of the Canal & River Trust | would like to repeat our sincere condolences to the
family of Mr Holgate.

[understand that in the report under paragraph 7, schedule 5 of the Coroners & Justice Act 2009
and Regulations 28 & 29 of the Coroners (Investigations) Regulations 2103, addressed to IE
MEE Safety Advisor at Canal & River Trust (CRT), you specifically asked for a review of four
aspects of the tunnel operation, namely:

Communication within the tunnel.
Wearing of lifejackets or buoyancy aids.
Wearing of safety helmets.

Review of safety information given out.

PONSa

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

The review concluded as follows:

1. Communication within the tunnel

It is clear from the evidence heard at the inquest that in some sections of the tunnel the use of
sound signals can be ineffective as a mean of communication to persons at the entrances to the
tunnel. This is more likely in circumstances where a boat has become separated from the usual
convoy arrangement, whereby boats transit the tunnel in groups. Harecastle Tunnel is unique in
the regard that it is the only one of the 45 Trust managed canal tunnels which has a mechanically
driven ventilation system, with doors which close behind boats when they enter the tunnel to
facilitate tunnel ventilation. Harecastle Tunnel is one of only 3 tunnels where personnel are present

Canal & River Trust First Floor North Station House 500 Elder Gate Milton Keynes MK9 1BB
www.canalrivertrust.org.uk

Patron: H.R.H. The Prince of Wales. Canal & River Trust, a charitable company limited by guarantee registered in England and Wales

with company number 7807276 and registered charity number 1146792 registered office address First Floor North, Station House, 500

Elder Gate, Milton Keynes MK9 1BB

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

2. Wearing of lifejackets or buoyancy aids

There is no mandatory requirement that lifejackets or buoyancy aids must be worn or carried on
inland waterway vessels. The Trust does encourage their use on inland waterways, but the general
view of many inland waterway boaters is that lifejackets or buoyancy aids are unnecessary, but this
is an attitude that the Trust is trying to change. The Trust will continue to encourage boaters to
wear them in the interests of their general safety whilst boating, and we will make particularly
reference to safety in tunnels. In direct response to this tragedy we will be encouraging the wearing
of lifejackets at Harecastle Tunnel by means of the briefing given to boaters and their crew prior to
tunnel entry. As the majority of tunnels are unattended by Trust staff we will modify all existing
tunnel portal signs to include a clear recommendation to wear lifejackets. Additionally we will
conduct an education campaign using our communication channels with boaters, about benefits of
wearing of lifejackets/buoyancy aids. Although part of a continuous campaign we will complete this
initial work by the 31° March 2015 which is the start of the main boating season.

3. Wearing of safety helmets

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

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

4, Review of safety information given out

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

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

If you require any further information please contact me.

Yours sincerely

Head of Health and Safety
Canal & River Trust