Emily Lewis

To:  Hampshire, Portsmouth and Southampton Coroners Service 

Castle Hill,  
The Castle,  
Winchester,  
SO23 8UL 

Email: 

For the attention of Mr Henry Charles  
Assistant Coroner for Hampshire, Portsmouth and Southampton 

By email only 

Dear Mr Charles, 

24 January 2025 

Concerns raised in the Regulation 28: report to prevent future deaths dated 15 November 2024 
(the “Report”) following the inquest into the death of Emily Jane Lewis on 22 August 2020 

Further to our letter of 10 January 2025, this letter is Associated British Ports’ (“ABP”) response to those 
concerns raised in section 5 of the Report that ABP may have the ability to take action in relation to, in 
particular the matters relating to the use of its Southampton statutory harbour area (“SHA”) by small 
high-speed  craft  being  operated  for  commercial  purposes,  and  the  action  that  ABP  has  taken,  or 
proposes to take in relation to these concerns. 

It is made pursuant to our duty to give a written response to the Report in  accordance with paragraph 
7(2)  of  schedule  5  of  the  Coroners  and  Justice  Act  2009  and  regulation  29  of  the  Coroners 
(Investigations) Regulations 2013 (the “Regulations”). 

The death of Emily Lewis on 22 August 2020 was a tragic event that has been subject to prolonged 
scrutiny, as befits the death of any young person; ABP responded to the Marine Accident Investigation 
Branch’s (“MAIB”) investigation into the incident and its recommendations and, while ABP was not an 
interested party in the inquest proceedings, we welcome the opportunity to respond to your concerns 
with the aim of improving the safety of all harbour users.  

We  note  that  the  Report  has  been  issued  to  a  number  of  parties  and  that  these  are  predominantly 
government, trade and industry bodies. It is the case that ABP is the only commercial party not involved 
with  the  inquest  to  receive  the  Report,  showing  the  general  and  regulatory  nature  of  the  concerns 
identified, and their potential application to all harbour areas in the UK, and all port users.  

Our response is set out in detail below, however, in summary we: 

- 

respectfully wish to clarify the position regarding the risk assessments that were in place at the 
time of the SEADOGZ incident; 

 
 
 
 
 
 
 - 

- 

- 

favour a national, sector-wide approach led by the MCA, as the appropriate regulatory body, to 
the regulation of RIB craft being used for high-speed experience rides; 

set out the interim measures that have been put in place in the Southampton SHA regarding 
commercial vessels; and 

have issued a notice to mariners stating that AIS transponders are required for all vessels being 
used commercially in the Southampton SHA from 1 January 2025. 

Clarification regarding ABP’s risk assessments 

Before  addressing  the  concerns  that  you  have  raised,  we  would  like  to  clarify  a  potential 
misunderstanding in the Report regarding the risk-assessments that ABP had in place at the time of the 
SEADOGZ incident. 

In section 4 of the Report, you state that “ABP (the harbour authority) had not assessed the risks of 
high-speed commercial passenger craft operations in its area”. That is not correct. 

There are a number of high-speed commercial passenger craft that operate on a regular basis in the 
Southampton  SHA,  ranging  from  vessels  similar  to  SEADOGZ  to  the  Red  Jet  high-speed  ferries 
between  Southampton  and  West  Cowes.  The  passage  quoted  above  suggests  that  ABP  has  not 
considered the risks such vessels pose, which is not, and was not, the case and could lead to readers 
of the Report coming to the wrong conclusion.  

ABP keeps its  risk assessments  under continuous review and updates them as necessary to reflect 
developments in relevant risks, changes in regulation and lessons learned from incidents and events 
that occur across the sector. 

Since  May  2020,  before  the  SEADOGZ  incident,  ABP  has  had  a  risk  assessment  in  place  for  the 
Southampton  SHA  that  relates  to  the  risks  associated  with  a  high-speed  vessel  colliding  with 
navigational marks (SOT – 133-4) and another regarding the risks associated with a high-speed vessel 
colliding with floating objects (SOT – 149-6).  

Following a review of the risk assessments in place after the SEADOGZ incident, we amended SOT  – 
133-4 to specifically apply to vessels of less than twenty metres in length and  introduced a new risk 
assessment, SOT – 153-3, which applies to vessels greater than twenty metres in length.  

The size of vessels is considered to be the appropriate determining factor as it is a suitable analogue 
for passenger capacity. The risk profile, and therefore the control measures, for large and small high-
speed  passenger  vessels  are  materially  different.  ABP  considers  the  navigational  risk  posed  by 
commercial and non-commercial high-speed passenger vessels operating in the Southampton SHA to 
be substantially the same and therefore does not have separate risk assessments for them as it would 
not materially improve navigational safety in the SHA. 

Coroner’s concerns 

We have reviewed the concerns in the Report and consider a, b, and e in Row 5 to be those that ABP 
may have the ability to take action in relation to. As such we set out our responses to these concerns 
below. For ease of reference we have followed the numbering in the Report.  

a.  Whether consideration should be given to the licensing arrangements for ports authorities and 
local authorities to achieve an early, uniform and comprehensible framework of the use of RIB 
craft on high-speed experience rides, including crewing levels, manoeuvres, craft standards and 
risk assessments 

The licencing of all small high-speed commercial vessels operating in the UK, including RIB craft on 
high-speed experience rides, is complex and it would be appropriate for changes to be dealt with at a 
national level to ensure a consistent approach. 

2 

 
 At  the  local  level  for  Southampton,  Southampton  City  Council  (“SCC”)  is  the  licencing  authority  of 
pleasure vessels used for carrying passengers for hire pursuant to section 94(1) of  the Public Health 
Acts Amendments Act 1907, as amended (the “1907 Act”), with ABP acting as its appointed agent for 
inspecting  vessels  to  be  licenced.  However,  under  section  94(4)  of  the  1907  Act,  a  licence  is  not 
required for vessels otherwise licenced by the Secretary of State, such as  where vessels are certified 
to the Small Commercial Vessel Code (“SCV Code”).  

As such, if vessels certified to the SCV Code (as was the case with SEADOGZ) were required to enter 
into an additional agreement with SCC as a condition of a licence, SCC and, by extension, ABP as its 
agent, would be open to challenge for acting outside of their statutory powers. 

As  was  identified  in  the  MAIB’s  report  into  the  SEADOGZ  incident,  local  authorities  and  statutory 
harbour  authorities  have  different  approaches  and  powers  to  regulate  small,  high-speed  passenger 
craft,  even  in  a  limited  geographical  area  such  as  the  Solent.  Given  this  variation,  were  one  local 
authority or statutory harbour authority to implement a local regime to regulate high-speed experience 
ride operators, the operators could move their vessels to another SHA rather than complying with that 
authority’s requirements, undermining local regulation attempts. 

As such, any changes to the regulatory regime would be best implemented through a consistent national 
approach, led by the MCA, as the national marine regulator, to ensure that there is a uniform, consistent 
and  comprehensible  framework  in  all  UK  waters  that  is  properly  communicated  to  the  relevant 
commercial vessel operators. 

ABP is in favour of an appropriate national, sector-wide approach for the regulation of RIB craft being 
used for high-speed experience rides, led by the MCA, as the appropriate regulatory body, with support 
from  the  relevant  industry  bodies  that  HM  Assistant  Coroner  has  identified  in  the  Report  (the  BPA, 
UKMPG, RYA, and UKHMA). This would ensure that any requirements or additional safety measures 
that  are  considered  appropriate  are  consistently  applied  across  the  UK  and  that  they  are  properly 
communicated to all relevant port users and commercial operators. 

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

rides 

As stated above, ABP keeps its risk assessments under continuous review and updates them as and 
when necessary to reflect developments in relevant risks, changes in regulations, and lessons learned 
from incidents and events that occur across the sector.  

Following the SEADOGZ incident ABP reviewed its risk assessments and safety management system 
to assess whether they should be updated or whether any measures should be put in place, resulting 
in updates to its risk assessments for high-speed passenger craft. 

In addition,  ABP,  in consultation with the MAIB,  issued notice to mariners no.52 of 2024, which has 
been reissued as no. 22 of 2025 (the “NtMs”) to implement a register of commercial vessel operators 
in the Southampton SHA.  

The NtMs require all operators of small craft, boats or vessels undertaking paid work, training or carrying 
fare-paying customers in the Southampton SHA to provide certain vessel details to ABP. The NtMs also 
specify that the Port of Southampton may, if appropriate, inspect vessels in line with existing national 
standards  (such  as  the  SCV  Code),  agreed  codes  of  practice,  OEM  handbooks  and  similar 
specifications. 

The NtMs have been necessary as an interim measure due to the substantial length of time it has taken 
for  ABP’s  application  for  a  harbour  revision  order  to  be  processed  by  the  UK  Government.  The 
application was originally submitted in June 2020, before the SEADOGZ incident, and once granted will 
give ABP a broader power of general direction, thus giving it greater flexibility to regulate users of the 
SHA and support safe navigation. 

3 

 
 e.  The  need  to  consider  whether  there  should  be  provision  of  AIS  for  RIB  craft  to  facilitate 

monitoring and intervention in the event of unsafe practices being identified 

ABP supports the use of AIS transponders by all commercial vessels and has taken steps to promote 
their use  by vessels  operating in the  Southampton SHA through  issuing the NtMs, which require  all 
commercial vessels operating in the Southampton SHA to have an operational AIS transponder fitted 
unless they have been granted an exemption.  

It is ABP’s intention to issue a general direction to support this requirement once its harbour revision 
order application has concluded.  

While AIS is an important aid to navigational safety, monitoring the AIS tracks of vessels (or a specific 
class of them), identifying whether they are operating safely or not, and potentially intervening in their 
operation in the  Southampton SHA would be very challenging for ABP, require  dedicated resources 
(with associated costs), and may not materially increase the safety of harbour users. Statutory harbour 
authorities do not have the powers, expertise or resources to generally police all vessels in their SHA 
and bring enforcement action in the event of non-compliance. 

The Southampton vessel traffic service (“VTS”) area covers 274mi2 and is responsible for co-ordinating 
the  movements  of  large  commercial  vessels  in  Southampton  Water,  the  SHA  of  the  King’s  Harbour 
Master Portsmouth and the area within 7NM of the Nab Tower. On a weekend in the summer there are 
likely to be several thousand vessels of all classes, engaged in a variety of activities, operating in the 
Southampton  SHA.  Many  of  them  will  have  active  AIS  transmitters  and  in  most  circumstances  it  is 
unlikely to be possible to distinguish between a vessel being operated safely and unsafely from its AIS 
track alone. 

While ABP does have an on-the-water presence in its SHA and its pilot vessels and harbour patrol craft 
may intervene on an ad hoc basis if they witness harbour users acting unsafely while they are carrying 
out their other duties, this is secondary to their general function. 

ABP is committed to improving the safety of all harbour users and, as set out above, we keep our risk 
management  systems  under  continuous  review  and  update  them  as  necessary  to  ensure  that  they 
reflect changes in regulation and relevant risks, and developments in best practice learned from across 
all of ABP’s ports and the wider port sector.  

Should you require any clarification on any of the above, please let us know.  

Yours sincerely, 

Harbour Master, Southampton 
Associated British Ports 

4

British Marine Federation Limited 
Head & Registered Office 
Tagus House, 9 Ocean Way,  
Southampton, Hampshire, SO14 3TJ. 
Telephone: +44(0)1784 473377 
Email:  info@britishmarine.co.uk 

09/01/2025 

British Marine response to the coroners Regulation 28: REPORT TO PREVENT FUTURE 
DEATHS After Inquest LEWIS E J 22082020 (1) (1). 

We as an industry association take the safety of all the activities carried out by the 
industry and our members as a primary concern. This is why prior to the Seadogz 
accident, in 2010 as part of an industry collaboration, and on the evidence outlined by 
previous MAIB reports, we helped produce and publish the HSPV code which was made 
available to industry. Due to further concerns and developments in the type of craft 
used and activities being carried out this was further revised and republished in 2019. 
As stated in the MAIB report, one contributing factor to this tragic accident is that the 
operator was found not to be implementing either the HSPV code or the PCA’s (not 
British Marine affiliated) code of conduct. 

Further to the development of the HSPV code we made the use of the code a 
requirement of our membership for any operator carrying out his type of activity, this 
has been done through the British Marine constitution. 

I have provided responses below to each of the concerns outlined in the report: 

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

This would be down to the individual licencing and port authorities to establish, British 
Marine are happy to collaborate if requested to help set the framework up. Industry is 
currently waiting for the new sport and pleasure code to be bought into legislation, (this 
is currently in an industry consultation and is expected that the legislation will be 
passed later this year) which will go a long way to addressing many of the concerns 
although it recognised there will be an implementation period of the new code. In the 
meantime British Marine’s suggested interim step would be for the HSPV to become a 
licencing requirement, but this would be down to the licencing authorities to 
implement. 

b.  Whether interim measures should be considered to manage risks of high-speed 

RIB experience rides  

We are now expecting the new Sport and pleasure code to come into legislation later 
this year. We have taken interim measures by reminding our members of all the current 
available guidance through our Marine Talk articles. We have also sent direct emails to 
the appropriate members as well as mandated our members to use the HSPV code.  

 
 
 
 
 
 
 
 Some port and licencing authorities have also implemented further licencing 
requirements. 

c. Whether the existing BS EWN 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  

BSi are providing a full response to this concern which British Marine has seen and 
agrees with. Since the construction of the Seadogz vessel there have been further 
amendments to ISO 11591 which go some way to addressing this issue, however it 
could be argued that the wording could be improved to add further clarity. If believed  
necessary we are happy to support this proposal through the ISO small craft 
committee, this can be bought up at this year’s ISO plenary in May for discussion with 
all the relevant industry experts and national bodies. 

c.  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  

We agree consideration of seat and handrail design should be undertaken. 

The new sport and pleasure code under section 25.7 of the draft has a requirement for a 
risk assessment which includes – “The availability, suitability and effectiveness of 
handholds provided on board the vessel.”  

The HSPV code also has a section which states: 

Handholds - all seats should have handholds located in front of the passenger allowing 
them to hold on with both hands. These should be roughly at chest height and shoulder 
width apart. Consideration should be given to the potential loss of firm hand grip during 
cold conditions. Further consideration may need to be given to padding the rear facing 
back of a seat and associated handholds to avoid risk of facial injury to the passenger 
behind in the event of rapid deceleration. 

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  

Some port authorities are starting to implement this already such as ABP Southampton 
- SOU-LNtM-2025-022 Commercial Craft Operators.pdf. It is our opinion that carriage 
requirements should be based on the licencing authorities and operators risk 
assessments taking into consideration the type of craft, operations being carried out, 
operational area including navigational risks, traffic density etc and resources of the 
licencing authority to monitor and make us of the AIS data. 

 British Marine Federation Limited 
Head & Registered Office 
Tagus House, 9 Ocean Way,  
Southampton, Hampshire, SO14 3TJ. 
Telephone: +44(0)1784 473377 
Email:  info@britishmarine.co.uk 

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

As an industry association we aim to implement all MIAB recommendations that we 
have been given as quickly as possible and have acted on each MAIB report, either 
helping produce guidance (and revising said guidance where necessary) such as the 
HSPV code or ensuring that industry is aware of new guidance such as MGN 436. 

It is recognised throughout industry that the new sport and pleasure code is long 
overdue with the first MAIB recommendation to update it being back in 2011.

10 January 2025 

Henry Charles  
HM Assistant Coroner 
Coroner’s Office 
Castle Hill 
Winchester 
Hampshire 
SO23 8UL 

Via email to: 
and cc’d to: 
(hard copy to follow) 

Dear Mr Charles 

Inquest  into  the  death  of  Emily  Jane  Lewis  –  British  Ports 
Association Prevention of Future Deaths response to HM Assistant 
Coroner 

I can confirm that the British Ports Association (the ‘BPA’) is in receipt of 
the Prevention of Future Deaths report dated 15 November 2024 which was 
issued to a number of organisations following the conclusion of the Inquest 
into the death of Emily Jane Lewis. I am providing this response on behalf 
of the BPA in my capacity as its Chief Executive. 

In the first instance the BPA extends its sincere condolences to the family 
of  Ms  Lewis.  The  BPA  and  the  ports  industry  was  extremely  saddened  to 
hear  about  the  tragic  incident  on  22  August  2020  and  the  circumstances 
which resulted in her death. 

By way of background the BPA is a trade and membership body for ports in 
the UK. We represent the interests of operators that handle 86% of all UK 
port traffic, to Westminster, the devolved Governments, and other national 
and international bodies. We are an inclusive and progressive association, 

British Ports Association 
Speaking for UK Ports 

a: 30 Park Street, London, SE1 9EQ 
t: +44 20 7260 1780 

e: info@britishports.org.uk 
w: www.britishports.org.uk  

1 

 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
   
 open to all and committed to the fair treatment of ports up and down the 
country. 

As  our  membership  comprises  many  ports,  terminal  operators  and  port 
facilities, all of varying size, location and nature, we are able to draw upon 
a  wide  range  of  experience  and  knowledge  to  represent  our  members’ 
interests. 

We  promote  good  port  management  and  governance  and  membership  is 
considered by many in the sector as an indication of a safe and respectable 
port operation. The BPA’s secretariat facilitates a range of services and is 
the  go-to  body  for  the  dissemination  of  ports  policy,  industry  news  and 
information. 

We also have a strong network of non-port ‘Associate Members’, who add 
much to the value of membership. 

The BPA’s objects and purposes are: 

a.  To  promote,  further  and  protect  the  general  interests  of  port 

authorities and conservancy authorities; 

b.  To afford opportunities for the discussion and consideration of general 
questions  affecting  all  Members  or  groups  of  Members;  and  to 
disseminate information on matters relating thereto; 

c.  To take common action on any Bill, whether public general or local, 
or any proposed subordinate legislation or other matters that may in 
any way affect the common interest of Members; 

d.  To  take  action  with  other  bodies  having  similar  objects  and  port 

authorities abroad on matters of common interest.; 

e.  Generally to consult and co-operate on all matters of common interest 

to Members; 

f.  To assist Members in the exercise and performance of their functions 
in  relation  to  ports  and  conservancies  by  the  direct  or  indirect 
provision of services and advice for Members; and 

g.  The Association shall have power to guarantee the obligations of any 

other person firm or body corporate. 

British Ports Association 
Speaking for UK Ports 

a: 30 Park Street, London, SE1 9EQ 
t: +44 20 7260 1780 

e: info@britishports.org.uk 
w: www.britishports.org.uk  

2 

 
 
 
 
 
 
 
 
 
 
 
 The  BPA  recognises  its  roles  in  contributing  to  safe  operational  activities 
within ports and as set out in our latest Annual Report, in 2023 we were 
closely involved in the reviews of the Port Marine Safety Code (the ‘PMSC’) 
and the associated Guide to Good Practice by the Department for Transport 
and  the  Maritime  and  Coastguard  Agency  (MCA).  These  are  important 
guidance resources produced by HM Government and we have continued to 
promote the principles of the Code and worked with government to increase 
its  awareness.  Indeed  the  BPA  is  an  active  member  of  the  MCA’s  PMSC 
Steering Group and separate MCA navigational safety committees. The BPA 
understands  the  revised  PMSC  and  Guide  are  due  to  be  published 
imminently  and  the  next  MCA  compliance  review  is  to  be  undertaken  in 
2025.  

Further, we continue to organise online PMSC duty holder workshops, which 
we provide free to BPA member ports but encourage non-members to join 
for  a  small  fee.  We  also  introduced  a  new  introductory  course  version  in 
conjunction  with  specialist  consultants  in  2023  and  organised  more 
workshops in 2024. These will continue in 2025. 

The  BPA  follows  wider  issues  across  the  maritime  community  including 
reports  and  recommendations  promulgated  by  the  Marine  Accident  and 
Investigation Branch (the ‘MAIB’).  The BPA has also raised safety matters 
directly  with  the  MAIB,  for  example,  concerns  relating  to  pilot  ladder 
deficiencies  and  the  lack  of  national  regulations  on  alcohol  use  on 
recreational vessels. 

Importantly,  the  BPA  is  one  of  two  joint  quasi-shareholders  of  Port  Skills 
and  Safety  (‘PSS’),  the  UK’s  professional  safety  and  skills  membership 
organisation for ports, and the BPA has representatives on the PSS board, 
ensuring  that  it  remains  an  active  stakeholder.  We  recommend  PSS 
membership to our members, and over 130 ports and companies are PSS 
members. 

British Ports Association 
Speaking for UK Ports 

a: 30 Park Street, London, SE1 9EQ 
t: +44 20 7260 1780 

e: info@britishports.org.uk 
w: www.britishports.org.uk  

3 

 
 
 
 
 
 
 
 
 
 
 
 In terms of our structure the BPA is an unincorporated organisation and it 
has  no  regulatory  functions  or  statutory  powers.  We  exist  as  a 
representative  body  for  ports.    We  are  therefore  unable  to  compel  any 
person  or  organisation  to  take  action  but  we  can  advocate  and  promote 
safety  issues  within  the  industry,  which  we  do,  primarily  through  the 
promotion of PSS, who we consider is doing a good job of driving positive 
change in skills and safety in the port sector. 

Following  the  incident  involving  the  vessel  ‘Seadogz’  on  22  August  2020 
and  the  tragic  loss  of  life,  the  BPA  was  active  in  its  engagement  with 
industry stakeholders.   

The BPA supported the MAIB investigation into the incident and received a 
briefing on the investigation. The MAIB’s report made a recommendation to 
industry (which was issued jointly to the BPA, UK Major Ports Group and UK 
Harbour Masters Association) to “contribute to the development of guidance 
for  their  members  clarifying  the  requirements  and  best  practices  for  the 
in  their  areas  of 
oversight  of  small  commercial  craft  operating 
responsibility”. 

Prior to its final report publication I responded to the MAIB on behalf of the 
BPA on 1 January 2024.  In summary, the BPA responded as follows:- 

•  That this was a tragic case and our sympathies were with the victim’s 

family and others affected; 

•  That  in  general  terms  the  BPA  was  not  opposed  to  guidance  and 
confirmed  that  it  can  participate  in  the  process  of  developing  a 
common resource. The BPA’s view was that it is clear that there is not 
a  consistent  approach  across  all  areas  and  so  the  focus  and/or 
expectations should not be on any individual harbour authority; 
•  That  as  a  starting  point  any  guidance  needed  to  be  largely 
government  written  and  owned  and  queried  the  MAIB’s  request  for 
the  BPA  to  ‘contribute’.  The  BPA  requested  clarification  that,  for 
example, the MCA would lead; 

British Ports Association 
Speaking for UK Ports 

a: 30 Park Street, London, SE1 9EQ 
t: +44 20 7260 1780 

e: info@britishports.org.uk 
w: www.britishports.org.uk  

4 

 
 
 
 
 
 
 
 
 
 
 •  That the BPA was not insured to set safety critical guidelines or give 
advice  itself  but  could  instead  assist  by  promoting  and  amplifying 
guidance and would look forward to being constructively engaged;  
•  Finally, that if the government was adamant that industry should own 
any guidance the BPA could seek to encourage PSS to lead this, but 
this would be subject to discussion with PSS and their agreement. 

Following the provision of the BPA’s response I have corresponded further 
with  the  MAIB  in  relation  to  progress  following  the  recommendation,  in 
which  the  BPA  reiterated  its  preparedness  to  contribute  to  guidance  and 
again  explained  that  the  BPA  had  set  out  in  its  response  to  the  MAIB’s 
recommendation  that  it  considered  the  MCA  to  be  the  suitable  body  to 
prepare the guidance.  In this correspondence I also updated the MAIB that 
PSS had been consulted and did not consider it had the suitable resources 
or skills to prepare any such guidance at present. 

I  hope  that  the  above  is  a  helpful  summary  of  the  BPA’s  involvement  in 
matters  relevant  to  the  issues  identified  within  the  Prevention  of  Future 
Deaths Report.   

I  can  confirm  that  the  BPA  will  continue  to  work  with  other  the  UK 
government,  as  well  as  with  industry  bodies  and  to  participate  in  the 
industry’s efforts to ensure that the issues which contributed to the tragic 
events of 22 August 2020 are suitably addressed with a view to avoiding 
any future incidents. 

Yours sincerely, 

Chief Executive 

British Ports Association 
Speaking for UK Ports 

a: 30 Park Street, London, SE1 9EQ 
t: +44 20 7260 1780 

e: info@britishports.org.uk 
w: www.britishports.org.uk  

5

Mr Henry Chiles

Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton

BY EMAIL

10 January 2025

Dear Sir,

Introduction

Emily Jane Lewis: Prevention of future deaths report

1. We  write  in  response to  your  regulation  28  report  arising  out  of the  death  of Emily Jane

Lewis  (“the  Report”).  BSI  would  like  at  the  outset  to  express  its  deepest  sympathy  and

condolences for the family of Miss Lewis.

2. We are responding in particular to No.5 (Coroner’s Concerns) Item c in the Report:

“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.”

BSI’s role

3. BSI’s  role  as  the  National  Standards  Body  is  to  facilitate  expert  committees  to  achieve

consensus on industry standards and best practice and to act as the publisher of standards.

4. BSI itself does not interpret standards, nor does it retain in-house expertise on the subject

matter of standards. Further, BSI is not a regulatory body and is therefore unable to advise

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 on regulatory matters, which are a matter for HM Government. Further information about

BSI’s role as the National Standards Body is given in the Appendix below.

Background

5. Each  individual  standard  is  the  responsibility  of  one  technical  committee.    It  is  the

committee who is responsible for the technical content of the standard, not BSI.  In this case

the  relevant  standard  (BS  EN  ISO  11591)  is  an  international  standard,  developed  by  an

international  committee  managed  by  the  International  Organization  for  Standardization

(“ISO”)) to which BSI contributes through a local (British) ‘mirror committee’. Such mirror

committees  consist  primarily  of  experts  who  are  independent  of  BSI,  and  who  are  often

nominated  by  trade  associations,  professional  bodies,  research/scientific  institutions,

government  or  other  entities.  They  have  an  independent  chair  and  BSI  provides  a

committee manager and other support including an editorial project manager for national

standards.

6. Draft  international  standards  go  through  public  consultation  in  all  participating  member

countries including the UK, and the decision to publish is achieved through voting by the

various committees.

7. The international committee responsible for BS EN ISO 11591 is known as ISO/TC 188. The

responsible UK committee in this instance is known as GME/33 - Small craft. Its scope is:

“Under the direction of the Standards Policy and Strategy Committee, is responsible

for  the  UK  input to ISO/TC  188,  CEN/TC  464  and  CEN  (CEN/SS  T01:  Shipbuilding &

maritime structures) under the Recreational Craft Directive (94/25/EC, 2003/44/EC)

and British standards relating to small craft”

(see https://standardsdevelopment.bsigroup.com/committees/50000770).

2

© 2024 BSI. All rights reserved.

 Committee’s Response

8.

In order to assist the Coroner, BSI has referred the Report to GME/33. The committee has

explained:

a) BS EN ISO 11591 has recently been amended to improve the assessment for vertical field

of vision following a request from the Norwegian Maritime Authorities. That amendment

(ISO 11591 Amd 1 2023) includes a new requirement:

4.2.2.3 Annex A sets the procedure and methods to determine the level reference line and

to verify the field of vision in the vertical field for power-driven craft with steering wheel

or equivalent fixed installed direct control, which shall be followed.

b) In the earlier version of the standard, the obligation to ensure sufficient field of vision

did include the requirement:

A forward field of vision shall be provided directly in front of the operator's eye position

throughout the vertical field of vision and extending to at least 15° on either side of a line

forward from the eye position (see Figure 1) to the obstructed vision distance as specified

in  4.2.2.  This  may  be  achieved  with  normal  movement  of  the  operator’s  head  while

maintaining control of the craft.

c) The  amendment  was  intended  to  incorporate a  requirement  for  the  effect  of  the  full

loading of persons to be included in the evaluation of the operator’s field of vision with

the craft at its maximum running trim angle value to ensure that the actual operational

forward visibility is adequate and compliant with the standard.

3

© 2024 BSI. All rights reserved.

 9. The committee asks the coroner:

a) Whether the amendment already published meets the recommendation as set out by the

MAIB in this case?

b) Alternatively,  does  the  Coroner  or  MAIB  consider  that  there  is  a  need  for  an  additional

amendment aimed at ensuring temporary obstructions (passengers for example) are more

clearly  identified  as  a  restriction  to  vision  and  used  within  the  calculations?  Given  the

existing text it could be considered that they are already, but it is not as clear as it may be

able to be.

10. If the answer to paragraph 9 (b) is yes, GME/33 could propose an amendment to the ISO

TC188 chair and raise it at the next plenary meeting of ISO TC188, scheduled for May 2025.

11. The  committee  also  believes  that  it  would  be  useful  to  talk  to  the  investigator  to  clearly

understand  the  objectives  of  any  amendment  proposal.  Therefore,  BSI  on  behalf  of  the

committee  asks  the  Coroner  whether  there  would  be  any  objection  to  it  contacting  the

investigator of this particular accident to understand further the proposed amendment to

the standard.

12. We look forward to your response accordingly.

Yours sincerely,

Head of Governance & Risk, Knowledge Solutions

BSI, 389 Chiswick High Road, London, W4 4AL, UK

bsigroup.com | LinkedIn|

4

© 2024 BSI. All rights reserved.

 Appendix: The role of BSI as the National Standards Body

1. For  completeness,  BSI  sets  out  below  information  regarding  its  role  as  the  National

Standards Body (NSB).

The role of the British Standards Institution

2. BSI’s role as the NSB is established by Royal Charter. BSI has several governing documents

(available online):

a. BSI’s Royal Charter and Bye-laws 1981;

b. A Memorandum of Understanding (MoU) of 16 September 2024 between the United

Kingdom government and BSI in respect of BSI’s activities as the United Kingdom’s

NSB;

c. BS 0: 2021 ‘A standard for standards – Principles of standardization’ (BS 0)

3. Article 1.2 of the MoU provides that BSI’s role as the NSB includes:

a)

the  management,  co-ordination  and  understanding  of  British  Standards  and  BSI

standardisation products;

b) participation  by  BSI  in  European  and  international  standards  bodies,  and  other

international activity undertaken in the interests of BSI as the United Kingdom’s NSB;

c) publication, promotion, marketing, distribution and information activities concerned

with  British  Standards,  BSI’s  other  standardisation  products,  and  standardisation

generally;

d) support any corporate infrastructure activities intended, wholly or in part, to enable

paragraph 12(a) to (c) above.

The  Director-General,  Standards  has  the  primary  responsibility  for  the  activities  set  out

above. BSI’s present Director-General, Standards is Dr Scott Steedman.

5

© 2024 BSI. All rights reserved.

 4. BSI develops and distributes standards in response to the needs of UK stakeholders, which

include  UK  Government  and  business.  Standards  are  technical  documents  representing

good industry practice. They are voluntary documents drafted by independent experts, as

distinct from legislation or regulation from government.

5. BSI  is  a  non-profit  distributing  organisation.  In  addition  to  revenue  generated  from

membership and the sales of standards, BSI also receives some funding from Government

to  support  the  development  of  standards,  contribute  to  membership  of  international

standards organisations and to encourage stakeholder participation in standardization.

6. BSI’s standards development process requires open and full consultation with stakeholders

to  build  consensus-based  outcomes.  This  gives  standards  the  legitimacy  and  degree  of

market acceptance to be used for public policy purposes.

Interpretation of Standards

7. BSI does not provide its own interpretation of standards. Paragraph 4.3.2 of BS 0 provides:

4.3.2 Interpretation

Responsibility for interpreting a standard rests with its user, informed where necessary by

appropriate expert advice. Ultimately, the only body with the power to give a definitive

interpretation is a court of law.

To avoid undermining the basis for common expectations set out in 4.1.1, BSI does not

offer individual interpretations of standards.

However, any ambiguities, inconsistencies or possible errors notified to BSI will be referred

for consideration by the committee responsible for the standard, as will any proposals for

changes or improvements. These notifications are actively encouraged as a contribution

to the maintenance of a document (see also 6.2.1).

6

© 2024 BSI. All rights reserved.

 8. Where  appropriate,  BSI  will  refer  questions  of  interpretation  to  the  relevant  committee

experts, who might respond in their individual or collective capacity,  though it should be

noted that any such response does not carry the imprimatur of BSI nor would it have any

authoritative status at law. As noted in BS 0, only a court of record has the authority to issue

a definitive interpretation of a standard.

7

© 2024 BSI. All rights reserved.

Henry Charles 
Hampshire, Portsmouth and Southampton 
Coroner’s Office 
Castle Hill, The Castle 
Winchester 
SO23 8UL 

From the Parliamentary  
Under Secretary of State 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Tel: 0300 330 3000 
E-Mail: 

Web site: www.gov.uk/dft 

Our Ref: 

10 January 2025 

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.    

Yours sincerely, 

MINISTER FOR AVIATION, MARITIME AND SECURITY

Chief Executive
Maritime and Coastguard Agency
Spring Place, 105 Commercial Road,
Southampton, SO15 1EG

www.gov.uk/mca
29 January 2025

Mr Henry Charles
Hampshire, Portsmouth and Southampton Coroner’s Office
Castle Hill
The Castle
Winchester
SO23 8UL

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.

Yours sincerely

Chief Executive Officer

N/ 

I 

________________________________________________ 

INQUEST INTO THE DEATH OF EMILY JANE LEWIS 
________________________________________________ 

, 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 

1 

 
 
 
 
 
 
 
 
 
 
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N/

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 

2 

 
 
 
 
 
 
 
 
 
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N/

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 

3 

 
 
 
 
 
 
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N/

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:  

4 

 
 
 
 
 
 
 
 
 
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N/

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 

5 

 
 
 
 
 
 
 
 
 
 
 
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N/

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: 

6 

 
 
 
 
 
 
 
 
 
 
 
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N/

. 

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. 

7 

 
 
 
 
 
 
 
 
 
 
 
 
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N/

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 

8 

 
 
 
 
 
 
  
 
 
 
 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. 

Mr Thomas McLaughlin 

Director of R

imited 

Signed: 

Dated: 

r, I o,/2o2.s-' 

9

Mr Henry Charles 
Assistant Coroner, Hampshire, Portsmouth and Southampton                                                                           
Coroner’s Office 
Castle Hill, The Castle, 
Winchester 
SO23 8UL 

09 January 2025 

Reference: Regulation 28, Request for Response 

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.  

Yours sincerely,  

Director of Training and Qualifications

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. 

Tel: 
Email: 

UKHMA - PO BOX 312, MORPETH, NE61 9GN 

 (Executive officer & Secretary); 

 (Membership & Accounts) 

www.ukhma.org 

 
 
 
 
                                                                                                                                            
 
 
 
 
 
 
 
 
 
 
 
 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 

c. 

Kingdom and Crown Dependencies; 
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. 

Tel: 
Email: 

UKHMA - PO BOX 312, MORPETH, NE61 9GN 

 (Executive officer & Secretary); 

 (Membership & Accounts) 

www.ukhma.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

Tel: 
Email: 

UKHMA - PO BOX 312, MORPETH, NE61 9GN 

 (Executive officer & Secretary); 

 (Membership & Accounts) 

www.ukhma.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

Yours sincerely 

President – UK Harbour Masters Association.                      

Tel: 
Email: 

UKHMA - PO BOX 312, MORPETH, NE61 9GN 

 (Executive officer & Secretary); 

 (Membership & Accounts) 

www.ukhma.org

30 Park Street, London, SE1 9EQ 

By email only: 

Dear Mr Charles, 

I write on behalf of the operators of the UK’s largest port operators and their trade body the 
UK Major Ports Group (“UKMPG”). UKMPG represents the nine largest UK port operators 
who, via the 40 ports they run, handle three quarters of all the port volumes entering and 
leaving the UK and invest more than £500m of private sector capital each year in the UK’s 
ports and surrounding coastal areas. These ports include 13 of the largest 15 ports in the 
UK and the largest ports in England, Scotland and Northern Ireland and in most instances 
our members are also the Statutory Harbour Authority. Appendix A to this document shows 
the UKMPG members and puts them in the context of the UK ports sector. 

UKMPG and the British Ports Association are trade associations who support their 
members to interface with government and respond on behalf of the sector to emerging 
policy. We are not a regulator of our members and we do not feel it is for our organisations 
to clarify requirements or develop guidance to be followed. As an organisation we do 
champion the sharing of information and best practice to members, but that does not 
extend to developing guidance or interpretation of requirements.  

We will support any guidance and actions suggested, but this must be led by the Maritime 
and Coastguard Agency (MCA) with input from industry associations. We are, of course, 
wholly ready to work in conjunction with industry partners and government, on the basis 
that the MCA own the guidance and lead on this work. 

Yours sincerely, 

Chief Executive, UK Major Ports Group  

UK Major Ports Group Members 

Associated British Ports  |  Belfast Harbour Commissioners 

The Bristol Port Company  |  DP World UK  |  Forth Ports Ltd 

Hutchison Ports (UK) Ltd  |  PD Ports  |  Peel Ports  |  Port of London Authority 

Registered in England No. 2787097 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Rosyth

Glasgow

Hunterston
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Ayr

Dundee

Methil

Leith

Greenock & Inchgreen

Ardrossan

Belfast

Silloth

Tees

Hartlepool

Barrow
Fleetwood

Liverpool

Garston

Heysham

Hull

Goole

Immingham

Grimsby

Manchester Ship Canal

King’s Lynn

Great Yarmouth

Lowestoft

Ipswich

Swansea

Newport

Harwich International

Port Talbot

Bristol

Tilbury

Barry

Cardiff

London

Southampton

Teignmouth

Plymouth

Felixstowe

London Gateway

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