Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0294, written 23 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jul 2015 |
|---|---|
| Reference | 2015-0294 |
| Deceased | Michael Hanlon |
| Coroner | Philip Sharp |
| Coroner area | Cumbria |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Plateus Ltd
PO Box 3162, Rawlinson & Hunter
Woodbourne Hall
Roadtown
Tortola British Virgin Islands
CORONER
I am Philip Alan Sharp, Assistant Coroner, for the Coroner area of Cumbria
2
CORONER'S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On the 23rd April 2013 I commenced an investigation into the death of Michael Robert Hanlon who was
born on the 8th December 1990. The investigation concluded at the end of the inquest on 27th
May 2015. The conclusion of the inquest was that Michael died from
1(a) Drowning. His death was an accident.
4
CIRCUMSTANCES OF THE DEATH
On the 6th April 2013 Michal Robert Hanlon as a deckhand on a luxury boat M.Y.FAITH owned
by you. It came in to Antibes Harbour. He had worked a night watch and then worked for the
whole of the 6th April 2013 without rest or sleep. He with other members of the crew went out in
to Antibes to meet friends. He returned to the boat at approximately 11.30p.m but did not enter
it. He was seen walking on the boat until 00.11 on the 7th April 2013. At some point later
before 00.22 he fell from the upper deck of the boat hitting the quay before drowning in the
harbour.
1
5
CORONER'S CONCERNS
During the Inquest it became apparent that members of the crew had failed to gain entry to the
boat on returning from on shore. One crewmember had slept on deck. I also concluded one
crewmember had attempted to climb through a doorway on the upper deck near to the position
where the deceased had fallen. There was a possibility, but no finding was made, that the
deceased may have been endeavouring to enter the boat by this route when he fell.
I also concluded crewmembers and in this case the deceased were likely to have been asked to
work additional shifts when the boat came in to port, potentially causing tiredness amongst
crewmembers. Further the deceased’s work pattern did not match the shift rota and his time
sheet was not made up to the time of his last shift.
The system for entering the boat after 10.00p.m involved certain members of the crew having a
key, but otherwise requiring knowledge of a key code to obtain a key from a box situated at the
front of the boat. The key could then be taken to the entry door at the rear of the boat, a door
opened and then the key returned to the front of the boat in to the key box before the
crewmember would then enter the open door.
6
The MATTERS OF CONCERN are as follows:-
(i) The efficacy of the entry system for certain crewmembers who were returning to the boat
after 10.00pm.
(ii) The recording of and monitoring of crew working hours by the officers to ensure
crewmembers are not required to work additional hours unless the safety of the boat, crew and
passengers was in danger.
7
ACTION REQUIRED
In respect of:-
6 (i) above:
To provide all crewmembers with a key to enter the boat save when the owners/guests were on
board when a 24 hour watch should be implemented.
6 (ii) above:
To ensure that all officers properly record the crews shift rota and that working hours are
recorded daily and the captain should check periodically that this policy is being maintained and
overtime work justified to him when needed.
2
8
YOUR RESPONSE
Is required on the 31st August 2015
9
COPIES and PUBLICATION
I will send copies to:
Marine Response Insurers of M.Y.FAITH
United Kingdom Sailing Association.
1. The family of Michael Hanlon
2.
3.
4. The Maritime Coastguard Agency.
5. Cayman Maritime.
10
DATE: 23rd July 2015
P A Sharp
SIGNED BY CORONER ……………………………
Philip Alan Sharp
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
we ye tees eeveeer mer gene mee PLUTEUS LIMITED C/O Monaco Sports and Management SAM “Fst — Ouest”, 24 boulevard Princesse Charlotte, MC 93000, Monaco Phone : +377 93104250 Fax : +377 93104251 HM Coroner, Cumbria 65 Duke Street, Barrow—in—Furness, Cumbria LAI4 IRW Sent by Fax +44 1229 812202 31" August 2015 Dear Sir, RE: Rule 28 Report — Michael Robert Hanlon We refer to your letter of 23rd July 2015 addressed to Patrick Bond of Marine Response, and in particular the section “Regulation 28: Report to prevent future deaths” (PFD). We do not propose to repeat the contents of MME email of 15th June 2015 and the attachment thereto (“the Owners Submissions), but noting your findings and conclusions, for the record we hereby restate the Owners Submissions. We are keen to co-operate and address the concerns you have identified as a result of the inquest. However, please note that in doing so, no acknowledgement or admission of failings or liability is intended or to be inferred. At paragraph 7 of the PFD, you have identified two areas of “Action Required”, as follows: ito To provide all crew members with a key to enter the boat save when the owners /guests were on board when a 24 hour watch should be implemented (the First Action), and 2. To ensure that all officers properly record the crews shift rota and that working hours are recorded daily and the captain should check periodically that this policy is being maintained and overtime work justified to him when needed (the Second Action). (together, the Action Points). We understand from the terms of the Chief Coroner’s Guide to the Coroners and Justice Act 2009 (paragraph 173) and the specific guidance on PFDs issued in the Chief Coroner’s Guide No.5 (dated 4 September 2013) (paragraphs 24 and 30), that specific remedial actions should not usually be recommended in a PFD. Nevertheless, given the views you have expressed as to the action you would recommend if you were empowered to do so, we have referred the Action Points to both the captain of Faith, and Wright Maritime Group LLC (Wright Maritime) who are retained to advise on safety and security matters in relation to the vessel, In connection with the First Action, Wright Maritime and the Captain have both commented that providing keys to seafarers for access outside of hours has proven to be unreliable, unsatisfactory and impossible to control, particularly because keys can be lost or forgotten. This can potentially lead to problems with acces Pluteus Lintited is Incorporated in the British Virgin islands, Registered Number 1712376 Registered Office: Woodbourne Hall, PO Sox 3162, RoadTown, Tortola, British Virgin Istands. Registered Agent in Cayman Islands : Campbells Corporate Services Limited, Floor 4, Willow House, Cricket Square, Grand Cayman, KY¥1 -1103, Cayman Islands had and also to potential security breaches if the lost key is found by persons who are unauthorized to access the vessel. As part of a refit programme, commencing in 2014, a new, “keyless”, entry system has now been installed (after some delays, in summer 2015) on board Faith whereby each crew member on arrival is issued with a personal access code (rather like a cash withdrawal PIN code), which they can choose themselves (thus making it more memorable), which is unique and personal to them and which should be kept confidential. This has removed the need for keys, which is the common form of access in yachts of Faith’s age. Since inception, the keyless entry system has proved to be a reliable means of access and, in all the circumstances, is felt to be a better and more reliable means of access than providing each crew member with akey. At the time of the incident a system was in place such that if a crew man returned and could not access the interior of the vessel (for example, if the code — which at that time was a long standing general code, rather than a unique code issued to each crew member — had been forgotten) the crew member could either ring the ship’s doorbell or telephone in to the boat. In such circumstances the appointed duty watch keepers would respond to any incoming calls, including the door phone till 22:00 hrs, after which they retire. The telephone system is programmed such that any incoming calls which ring unanswered for more than 3 rings, will sound in the Captain’s cabin. Under the new system, with the unique personally chosen codes, it is considered far less likely that a code will be forgotten. Nevertheless, the back-up system of calling in will remain. Please also note that a 24 hour watch system is implemented in place of the keyless entry when the owner or guests are on board. The new keyless system that has been installed addresses the concerns you have set out in the PFD. However, we of course remain open to any further thoughts you have on this subject. In connection with the Second Action, a system of recording working hours and hours of rest is and has always been in place as per International Maritime Organisation and International Labour Organisation requirements. Given the concems you have identified in the PFD, steps will be taken by the Captain by means of a Captain’s Standing Order to ensure appropriate procedures are put in place to monitor those working hours and to ensure that crew members are not working additional hours without the requisite rest periods, in particular between shifts, unless the safety of the boat, crew and passengers is in danger. The Captain’s Standing order is to be issued in the week beginning 31* August 2015. We have concems with regard to the wider circulation / publication of this letter in particular in relation to Faith’s security arrangements, particularly when the owner and guests are on board. In the circumstances such information should be regarded as private and confidential, and not for wider circulation / publication. If we can be of any further assistance or provide any further information, please let us know. Yours faithfully, For and on behalf of Pluteus Limited i ~~ Director Pluteus Limited Is incorporated in the Gritish Virgin islands, Registered Number 1742376 Registered Office: Woodbourne Hall, PO Box 3162, Road Town, Tortola, British Virgin islands. Registered Agent in Cayman Islands: Campbells Corporate Services Limited, Floor 4, Willow House, Cricket Square, Grand Cayman, KY1 -1103, Cayman [stands
See every Prevention of Future Deaths report matching Accident at Work and Health and Safety related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.