Monday, 17 March 2025 (9.59 am)
MR GEORGE PAPADOPOULOS (affirmed)
SIR ROSS CRANSTON: Well, good morning, everyone. Good morning, Mr Papadopoulos. In a moment, Rowena Moffatt has a few questions for you, but if you could first of all read the affirmation.
A. Of course, yes. (Witness affirmed)
SIR ROSS CRANSTON: Thank you very much. Ms Moffatt.
Questions by MS MOFFATT
MS MOFFATT: Could you please state your full name?
A. Yes, my full name is George Papadopoulos.
Q. Mr Papadopoulos, you made a witness statement dated 31 October 2024, which is 38 pages long; correct?
A. That’s correct.
Q. You are currently employed by HM Coastguard.
A. That is correct.
Q. You joined coastguard in 2015 as a MOO, maritime operations officer; correct?
A. Yes.
Q. And you were promoted to senior maritime operations officer, or SMOO, in 2017; correct?
A. Yes.
Q. You became a search mission co-ordinator in 2018; correct?
A. Yes.
Q. And in 2020, you were again promoted to team leader.
A. Correct.
Q. And then on 6 August 2021, you were promoted to channel operations tactical commander —
A. Correct.
Q. — which is your current role.
A. (Nods).
Q. I understand that in November 2021, your role was also known as the small boat tactical commander; is that correct?
A. Correct.
Q. In terms of your current role, you talk about this in your statement. If I could have that on screen, please, at paragraph 14, so it is {INQ009632/5}. First line of paragraph 14, you say: “My appointment was to provide a designated lead in relation to migrant [search and rescue] due to the volume and concentration around Dover.” And then, second line: “Further recruitment was envisaged but this has not yet come to fruition.” So this has not come to fruition as at today, 17 March 2025?
A. That is correct. If I do — may put a bit of context behind it. So there was an intention to recruit a second role. However, that hasn’t come to fruition and that’s not the intention any more as well.
Q. I see. So the initial intention was to create another one of you, essentially, two in the same role, is that right, or a different role?
A. Yes, same role, to support due to the operational requirements at the time of my role, which obviously is not the case any more because my role is not operational.
Q. Let’s come on to that, then. So there is no longer any second role in the pipeline. That’s now been dropped.
A. Correct.
Q. Now, a few weeks before your appointment in August 2021, the role was described in an email from Mike Bill, the divisional commander for division 2, including Dover, so let’s put that on the screen, can I have {INQ003195/1}. Now, this is an email from 29 July 2021 and it is from Mike Bill, as I said, to the then chief coastguard, Peter Mizen, amongst others. Halfway down the page there, you can see a paragraph starting: “George will undertake …” Do you see that one?
A. Yes.
Q. So: “George will undertake a lead function for migrant operations across all watches. He will review and oversee Dover’s response to migrant incidents ensuring [standard operating procedures]/Policy is understood and followed including washup/debriefing of identified incidents. Should policy change George will deliver training to all watches on updated SOP and ensure understanding. George will retain line management of his own team. George is happy to take on the role and wishes to remain operational still managing his watch.” I understand things have changed since and we will come on to that, but does this describe the role as initially envisaged?
A. Yes, I’d say it’s an accurate summary of the role at the time, yes.
Q. Then we know you were appointed on 16 August. Then in September, we can see another email from Mike Bill, so this one is {INQ008621/1}, please. So page 1 there at the bottom, we can see the email from Mike Bill. There is a lot of redaction there for data protection purposes, but it is to the team at Dover. The email starts — go on to page 2, please, {INQ008621/2}: “Good afternoon Dover team.” And then the first two paragraphs are introductory and Mike Bill essentially thanks the Dover team for, in his words, keeping the ship afloat and referring to efforts made to bolster support for Dover and to increase headcount. Excuse me. He then turns to your role, third paragraph, and starts: “I’m advised …” Do you see that one?
A. Yes.
Q. So: “I’m advised that there is some confusion over the new role which George has taken on and hopefully I can clarify: “George’s main function is to act as a tactical commander in the Dover ops room on Red days when he will release the network commanders from requirement to oversee the migrant incidents and take over the RAG function for those incidents.” So just pausing there, would you effectively become the maritime tactical commander for Dover on red days?
A. Yes, that is correct. So the intention was for me to be present on red and amber days as much as possible, considering that I was a single person dedicated to small boat crossings at the time. So the intention was for me to be readily available on red and amber days, primarily looking at the time based on the volume of incidents during the hours of day hours, so usually a day shift start. However, I was also on-call, which meant I could be contacted to be available when and as — as required as well.
Q. We will come on to you being on-call, but just now, since you have mentioned it, does that mean that — did you have specific hours when you were on-call? Was there a rota or were you just on-call whenever anyone needed you?
A. So, again, the difficulty with being the single maritime or small boat crossings tactical commander at the time was I was on-call 24/7 as the single point of contact. So, again, because it was quite early on, the role in its creation, and this role was intended to be shaped into — into the future around small boat crossings anyways, so yes, I was on-call 24/7, along with me being quite flexible to support the operational requirements at Dover as a tactical commander.
Q. And as a result of you being there in the ops room being — taking on essentially the tactical role, that would then mean that the maritime tactical commanders at the JRCC wouldn’t need to oversee RAG review of any of the small boat incidents; is that right?
A. That is correct. So the RAG function was coming on to myself as a small boat crossings or migrant tactical commander. As part of that function as well, obviously I was supervising the teams at Dover in respect to welfare and any further requirements. So if I did identify or the team leader or the SMC identified that we required further support from the network, it was my duty to ensure that I contact the JRCC or the network tactical commander to make sure that they take action and they provide me and the team at Dover with that support as well.
Q. Let’s continue reading. So midway in that paragraph that we were looking at, so it starts: “Where this may change …” Do you see what?
A. Sorry, which paragraph?
Q. In the middle of the paragraph that starts: “I’m advised …”
A. Yes, yes.
Q. So we read up until “those incidents”, so picking up again at, “Where this may change”. You have got that?
A. Yes.
Q. So: “Where this may change is if George sees that the MRCC are struggling to handle the volume of incidents due to low staffing and with no SMC and on those occasions, if he considers it necessary, he may play a more hands on role as the SMC handing back the tactical command to the network commander.” So essentially where — due to low staffing or you can see the staff are struggling in Dover, then you would essentially hand the tactical role back to the JRCC and you would become operational, taking on the SMC role. That’s what that suggests; is that right?
A. That is correct. So automatically, if there was no SMC at Dover present, it would only make sense myself, as SMC qualified as well, to take that role operationally and let the JRCC tactical commander to maintain tactical supervision of small boat crossings, so —
Q. Even if there was an SMC — for example, on the day, 24 November, there was an SMC in place, James Crane, but you still handed back the Tactical Command. So even if there is an SMC and there’s too much work essentially, you would still hand it back; is that right?
A. That is correct. So because I was still present at Dover MRCC and we all know, and it’s been highlighted previously, that physical presence during those busy days at Dover is critical and beneficial, so under those circumstances, again, it will make sense that I hand over Tactical Command to the JRCC tactical commander and myself become operational. Obviously, if there were no SMC, I would be the SMC. If there was an SMC, like we have discussed, it is quite evident I would — in my capacity as mission co-ordinator, MC qualified, I would take that role as well to support the teams.
Q. You said it is critical to be in Dover on those busy days. In your view, how did being in Dover compare with remote cover, for example, from the JRCC? Could anything be missed if you were remote?
A. Again, if we look at the small boat crossings search and rescue operations at the time and even more now, they are a joint response in the sense that we rely on partner agencies’ assets to support such rescue operations. So in short, yes, it’s highly beneficial that — to be present during those busy days at Dover because of the information exchange that takes place within the operations room. There is lots of discussions, lots of interaction, which obviously it’s hard to duplicate if you are remote. And those live conversations/interactions assist with further decision-making to be quicker and more efficient, so yes.
Q. Let’s go back to the email, next paragraph, which starts: “Where time allows …” Have you got that one?
A. Yes.
Q. So: “Where time allows …” And it refers to you needing obviously some work/life balance. You will also attend on likely busy amber days and Mike Bill says: “We are also looking at George going on to A&T so that he could be called/recalled urgently if required. George will work on the criteria for such a call out and this will eventually be posted on CIP.” That’s the intranet, isn’t it, the Coastguard Information Portal?
A. Correct, yes.
Q. Do you recall how often, if at all, you attended on amber days in November 2021?
A. I would say quite often. Obviously the priority was on those assessed red days, followed — followed by amber days and subsequently yellow days as well, so obviously I was prioritising my attendance based on that Op Deveran assessment, the weather assessment, keeping in mind as well that work/life balance and rest time.
Q. So we are referring to days here, but obviously there were red and amber nights as well.
A. (Nods).
Q. Do the days actually include nights as well in this email?
A. Correct. So by default, however, we all knew that it was usually after a 7.30 start in the morning that the workload started picking up because usually, that was when the small boats were expected more or less to be successful in crossing into UK search and rescue.
Q. Just so I understand that, you are saying on a day shift after 7.30 in the morning, or did I mishear?
A. Yes, so in general, if you look into some stats and data at the time, so small boats were aiming to cross through into UK search and rescue region later on the day. So that was usually between 6.00 — let’s say 6.00 and 11 o’clock in the morning. Obviously, with the crossings and the small boats stacking up, let’s say, and the workload increasing, it was prominent that — it was during daylight hours that we were becoming busier as a search and rescue co-ordination centre because of the volume of vessels coming closer to the median line, and that’s where obviously it’s critical to make sure our response is preplanned and in place to support the operations.
Q. So does that mean that generally, you would be there on the day shifts?
A. Correct. So my intention was to aim for a 7.30 start. Sometimes, again, I took it upon myself, and discussions followed with my line manager and senior managers as well, to start one or two hours earlier, so maybe like a 5.30 or 6.30 start for my 12-hour shifts, but that was quite dynamic and as — as required. Again, me being on on-call roster, I could easily be contacted to be asked to start earlier than, for example, 7.30. So the capability was there for myself to be asked to come in early, especially if it was an observational requirement by the JRCC maritime tactical commander or even the duty SMC.
Q. And that paragraph also refers to you going on A&T.
A. Mm-hm.
Q. Could you just tell me what that means?
A. Yes, A&T stands for the alerting and tasking software platform, so that is the universal platform we are using not just for tasking coastguard rescues teams and paging teams, but also every single officer within HMCG that is on an on-call roster is within this platform. So I followed the same process like everyone else who is on-call, and everyone has access to that A&T platform, so anyone could have requested for me to be paged, effectively. Again, I see it’s been mentioned. I did work through that criteria to make sure there is a clear guideline. However, up until that criteria was drafted and published, it was clearly communicated that if you need me, call me or page me and we will see what I can do to be available.
Q. So from August, you were, as you said, 24/7 and anyone could call you.
A. Correct.
Q. And then you worked out a criteria for a call —
A. Correct.
Q. — and that was posted on the Coastguard Information Portal, was it?
A. Correct, along — followed with, as you have previously heard, like a hot topic or a hot update communication that goes to all of the network within HMCG. Obviously, and I can’t recall, it will have been certainly an email as well to enhance the communication and update as well.
Q. Do you recall when those criteria were put on the intranet?
A. I can’t recall, I am afraid.
Q. Next paragraph then, so the one that starts: “Other than his role within the ops room …” Do you see that one?
A. Yes.
Q. This refers to two other functions of your role. So you were to lead on training and familiarisation of staff with updates on SOPs and policy relating to small boat search and rescue; correct?
A. Correct.
Q. Then also, you were to represent coastguard — HM Coastguard outside of the ops room in meetings relating to small boat activity.
A. Correct.
Q. Correct? And the final paragraph says that essentially, if there are long periods where there is no small boat activity, you would have a management role at Dover. What did that entail?
A. So it’s already been quite evident within one of the emails that I will have line management responsibilities. So previously to being offered this position, I was a team leader, so I was team leader for team 1 at Dover. Obviously me taking up that promotion opportunity meant that potentially — not potentially; there was a gap of leadership within team 1, which was compensated with myself still being the line manager for team 1. So I was still line managing team 1, effectively, at Dover whilst performing my — that new role as a tactical lead.
Q. I see. Now, I understand that red days can be back to back. I am calling them days. Red shifts, let’s say.
A. Yes.
Q. So you can have a red night watch followed by a red day watch. How would you prioritise which one of those to cover, bearing in mind obviously you couldn’t work for 24 hours in a row?
A. Again, as a matter of principle, we will prioritise for me to be available during the day shift of a red or amber or yellow day, unless it was clearly identified that I had to be available and present at Dover during a night shift or with an earlier start other than 7.30. Hence why the on-call capability was there for myself, because it was easier for me being the single person — not easier, but easier to manage to be available by default during a day shift and if that requirement changed because of, for example, becoming busier during a night shift, so it was becoming evident that actually my presence operationally at Dover was much suited for me to start earlier during a day or into a night shift, it was there. But obviously, again, being a single person within this — this role and to ensure my welfare as well was to be, by default, available for a 7.30 in the morning start on a red, amber, yellow day, unless that changed due to the volume of operations the preceding night.
Q. Was one person enough for the role in 2021?
A. It became evident a few months into the role that one person was not enough, hence why there were discussions and attempts to recruit for a second role.
Q. Do you know why that didn’t come to fruition?
A. So there was one or two recruitments for this role through the Civil Service. However, we — unfortunately, we didn’t have any successful applicants through — through the interviews. So it was an ongoing effort to recruit. Obviously, applicants didn’t meet the required standard. Just to clarify, I wasn’t part of the recruitment process as well. And by the time — well, at some point in my career with this — within this role, there was an informed decision made to come off operations and at that point, obviously, the decision was also made that if — “George, if you are not operational at this stage, we don’t believe there is a requirement to — to have a second person in this role”, which obviously at the time as well made sense.
Q. And let’s then look at that. So let’s go to your statement paragraph 27, so this is {INQ009632/12}. There we go. So here, just the fourth line down there, you see. “My role was reviewed in 2023 and is no longer operational …” As you have just been telling us. So does that mean that you are no longer playing the role or taking on the role of the tactical commander on red days, or how has it changed?
A. So that is correct. So one of the aspects is I am no longer acting as a tactical commander for small boat crossings. I no longer act as an SMC. I no longer act as an MC. So there is no expectation from myself to be operational in any shape or form.
Q. And do you think that there is no longer a need to have someone who — so a specific small boat maritime tactical commander?
A. Sorry, is that a question of what I think or how things have been communicated and decided?
Q. What you think. You had the role. You no longer have that operational role. Is that something which you think is no longer needed?
A. My — my personal opinion on the matter is that we have sufficient measures in place with the concept of network within the coastguard, the wider network, to support me coming off operations. As you probably know, at the time, we were — HMCG was struggling to have more than one maritime tactical commander within the ops room. Now, obviously, the headcount at the JRCC has increased to three, I believe. So the capability is there and it’s — it has been enhanced. However, I do think that there is still merit in, obviously, us with an SMC to be based at Dover and be available for those busy days as well to have — it will have been beneficial, in my opinion, personal opinion, to maintain Tactical Command at Dover as well, especially now considering the fact that Home Office/Border Force maritime, they — they are co-located, and looking into JESIP principles, into co-operability, etc, it would make sense to maybe consider maintaining that tactical presence on station at Dover. And that — again, based on my personal opinions, just before I was taken out, the operational aspect of my role and working with the joint control room, again, JCR, as we all know, based at Dover and their Tactical Command, if I may say so, we did have really good conversations and discussions dynamically at that tactical level at Dover to again enhance that decision-making and efficiency of response quite quickly. It was quicker to resolve not difficult aspects of the operations, but to reach an agreement between ourselves and Border Force maritime and the JCR to make sure that we were on the same page, effectively.
Q. So now the — you said there are three maritime tactical commanders at JRCC on shift at the same time, presumably.
A. I think that’s — that’s the goal. So each of the four teams has three maritime tactical commanders, JRCC network — sorry, network commanders assigned, so you are looking at 12 in total in rotation.
Q. So there’s always someone to do the RAG reviews for —
A. Yes, I would say it is quite unlikely to have less than two JRCC network commanders on duty at the same time.
Q. When you are saying “network commanders”, is that the maritime tactical commander?
A. Yes, the role has changed, but effectively, from a tactical perspective, is the same.
Q. And you say that you are still on-call and you share that role with Neal Gibson, who’s now the rescue co-ordinations centre manager; is that correct?
A. Correct. I am still on-call, but in a different context, if I may explain or if there is —
Q. Please go ahead.
A. Yes, so at this stage, I am still on-call, which I share with Neal Gibson to ensure that we cover 24/7 the on-call element, and that’s as the small boats tactical adviser at this stage. So it’s not an operational role, but due to my experience and the role itself, I am available as an adviser, whether that’s an adviser to the SMC or the network commander or the duty strategic commander. And, again, there is a set of criteria that has been revised and republished to support this.
Q. I want to turn now to resources at Dover. We can take the statement down. Thank you. In your statement, you say you had no concerns about staffing on the day watch of 24 November 2021 —
A. (Nods).
Q. — or more widely. You say you weren’t aware of any organisational concerns about low staffing at Dover. We have already seen the email from Mike Bill about your role, where he referred to keeping the ship afloat at Dover and to efforts to bolster support and to bolster headcount. So you must have been aware that those above you were taking steps to increase staffing at Dover in 2021; is that fair to say?
A. Yes, that’s correct.
Q. Mike Bill has also provided evidence to the Inquiry about his concerns about the staffing shortage at Dover and staff welfare concerns as a result. Were you aware of those?
A. I was aware of those as a team leader and initially as part of my new role at the time. Obviously, that’s quite important to remember; that I transitioned from being a team leader, operation team leader, into an SEO senior management role. So obviously, as my role evolved and I took up this opportunity, I had access to senior leadership discussions, meetings and information, so I was still enhancing my understanding around matters and issues and how senior leadership considered and tackled those.
Q. So you were aware about the staffing problems?
A. I was aware at the operational level and obviously, within my new role as well, I was becoming aware of other matters and concerns as well.
Q. And let’s look at the week in question. This is the week commencing Monday, 22 November 2021. You attended what’s called the red days meeting on that day. Let’s put the meeting notes on the screen, so this is {INQ000206/1}, please, and we can see you there along with various other people from coastguard: Pete Mizen, the then chief coastguard; Duncan Ley, strategic commander; Mike Bill, your line manager at that stage, was it?
A. Yes, correct.
Q. So page 1, we can see it took place 4.00 pm on Teams, 22 November. Now let’s go to page 4, please, under the heading “Staffing” {INQ000206/4}. You see at the top there “5. Staffing”. At the top of the page, there’s discussion as to numbers in the network as a whole, which are said to be healthy, above minimum to the JRCC and it’s said that support to Dover could take place smoothly, presumably remote support. Then there is a reference to numbers at Dover being low. We see the first paragraph, three lines up: “… 2 … on night …” Then underneath that, we see PM, which is the then chief coastguard, says: “… Two SMCs at Dover on nights isn’t enough …” It’s understood, actually, that it should mean two staff, not two SMCs at Dover. So even knowing that there was remote support from the JRCC, the chief coastguard then considered that two staff at Dover was insufficient. Is that your understanding?
A. Yes, that is my understanding, and it also made sense that if we are expecting a busy night and day, having two staff at Dover is not enough.
Q. You have already told us about the need to have people on the floor of the ops room in Dover as opposed to JRCC. Is that again reflecting those concerns around the need to have people in the room in Dover?
A. Correct, one aspect of that, yes, yes.
Q. There is then a discussion of potential mitigation options in the meeting. We can see you halfway down the page. Do you see “GP”? That’s you, isn’t it?
A. Yes.
Q. You say there is: “… No response locally for overtime, additional action would be an A&T message to get interest from the wider network.” So, again, that’s referring to that on-call system, is it, the A&T?
A. Correct. So, again, another capability that this system offered was to contact operational staff, so maritime operations officers, senior officers, SMOOs, for example, and SMCs as well. If they have opted out to be contacted through the system, we could have asked them via a text, in an email, whether they were willing to take up overtime.
Q. I see. Then there is a discussion as to whether Richard Cockerill, who was travelling to Dover to provide support, could alter his hours, and we know he started his shift on the 24th at 5.00 am, so a couple of hours earlier than normal. And then there is further discussion, which is the last line on page 4, around high numbers of crossings and the risk of earlier and large scale small boat activity on amber days, which was a new thing, as I understand it, developing around that time in 2021.
A. (Nods).
Q. And then page 5 {INQ000206/5}, top of the page, you see there DL, Duncan Ley, asks if any staff can move from days to nights. It is acknowledged there is not likely to be volunteers for that. So you would agree that you were aware of staffing concerns in the beginning of that week, so the week commencing 22 November?
A. Correct.
Q. Do you remember whether such discussions around staffing at Dover were a feature of other red days meetings that you attended?
A. I can’t recall, but looking back on what the standard for those meetings — you know, the standing agenda was, it will have most definitely been discussed, because it is quite critical to ensure that we do have the response and the response is not just the assets. It’s also the resource within the ops room.
Q. In that meeting, there was also a discussion about asset availability and taskings.
A. (Nods).
Q. Who would be responsible for the search and rescue planning, including asset taskings for each red day or amber day?
A. So in relation to planning, I just need to clarify if we’re talking between — so just to clarify if we are talking about Border Force maritime assets and how they are planned, obviously that was, at the time, for Border Force maritime to plan accordingly, but also they were obliged to tell us what potentially may be available for us to request dynamically. It’s already quite known that the way it was working with the Border Force maritime assets was we had to request those through Border Force MCC over a phone call and those assets were made available to us. But, again, part of this meeting, planning meeting and discussion, was to make sure that we convey the requirement for as many assets, let’s say, to be available to us on the night or the day. Then if we are talking about, again, RNLI assets, those are requested dynamically again, but obviously being declared assets, we need to make sure that we have a common picture of what’s available and what’s not available to us. And the same with aeronautical assets as well; whether they are tasked proactively or reactively, just to understand what we have got on paper available to call upon.
Q. The Home Office should have been at this meeting, but apologies were sent. Would that be a problem if the Home Office didn’t attend meetings in terms of search and rescue planning, asset planning?
A. Again, because that was quite — you know, you can appreciate it was quite early on me accepting this role. Me accepting the role in August up until November, again, considering leave I have had over the summer, I was still, let’s say, finding my feet within this role and make sure that — my priority was that operational support, so to be available. So it will have been an issue? I’d say no, because we will have expected for any lack of planning or support from Border Force perspective to be clearly and explicitly communicated to us. But the way it was working with Border Force maritime and their assets at the time was that, “We do have assets. You ask for it.” If it’s not available, we have to consider obviously RNLI and other methods of response. But I would say it wasn’t — it wasn’t safety critical, let’s say, at the time.
Q. I think you talk in your statement about the difference between proactive tasking, so, for example, the surveillance taskings done by 2Excel or the aerial assets, and the reactive tasks, which — I understand RNLI would be in that category, but obviously you’d need to know how many assets were available. In terms of the proactive taskings, who would decide what needed to be tasked? Would that be something you would do or would it be something above you?
A. So at the time, again, trying to understand myself, my role to be shaped into the best, best thing it could become at the time and for me to provide was, at the time, if we look at proactive tasking of aircrafts — whether it is 2Excel or RVL, it doesn’t really matter, but if there was a requirement for proactive tasking of aeronautical assets, at the time, it was something that — it was slowly coming my way. So there was already a process in place for those proactive taskings to go through. It was someone within HMCG or JRCC, so the Joint Maritime Security Centre at the time. We do have roles within that area of work, so it was primarily the officers working within JMSC for the coastguard looking into those obvious requests and the assets to be tasked. At the time, if I can recall correctly, I was in the process of taking up that aspect, so for me as a single point of contact to — to proactively request and — request those aeronautical assets.
Q. So it became part of your role, but perhaps at the time, you were still developing —
A. It was still developing, but obviously, it will have been no chance for it to be missed because, knowing me, I was quite interested to know as a tactical commander — expected to be tactical commander know what assets I had available and if I did identify any lack of assets to, again, ask the question and make sure that the requirement was clearly communicated for those assets to be available to us.
Q. Thank you. We can take these notes down. Thank you. I want to now talk about experience and training in relation to small boats. Now, you said in your statement that the issue of migrant crossings is not a new concept to coastguard, to HM Coastguard. Do you mean by that that it’s not new since around 2018 or do you mean that it went earlier than that?
A. I can’t recall if it went earlier than that. Probably did in a really smaller scale, but definitely from 2018 onwards, it was quite evident that it was an aspect of search and rescue operations we needed to focus on and make sure that we learned more about it to adapt as a search and rescue authority.
Q. You have called it a defined category of the routine search and rescue work undertaken. A subcategory of it?
A. As part of the search and rescue, you mean?
Q. Mm-hm.
A. Yes, because it still comes under search and rescue. It’s just small boat crossings search and rescue has a few idiosyncrasies, obviously, the joint response element being — being one of them and how busy it can become quite — quite quickly, and the reliance on, for example, information from the French coastguard and aeronautical assets as well.
Q. Is HM Coastguard used to having subcategories of its routine SAR work, or is that something which was different in relation to small boats?
A. Not necessarily. In a sense, for example, if you think search and rescue is anything and everything, it could be, you know, people in the water, mass — mass casualty event, it’s still search and rescue, just that it’s part of — if you want to, you know, give it the title of being a subcategory, it doesn’t take any — anything away from it. It’s still search and rescue, just to make sure that we highlight the requirement for further development and adaptation into our response.
Q. Now, you have said in your statement that you didn’t receive any specific training on small boat crossings, but you essentially learned on the job and had firsthand experience from working at Dover.
A. Correct.
Q. As we have seen then, turning to your role in training and development, this was one of your key responsibilities as the — in your new role in August 2021, developing training essentially and policies in relation to small boats. We have seen that you were appointed as the small boat tactical commander on 16 August 2021 and you have said in your statement that the first few months of your appointment were primarily operational and dealing with small boat activity. By this, do you mean that you were filling gaps in the operations room, still deep in the operational detail at that stage?
A. In essence, yes. So obviously myself, alongside my manager and senior management at the time, we had to prioritise what my role and what gaps potentially — let’s say gaps — what responsibilities I had to fulfil as a matter of priority and, obviously, the priority at that time was clearly identify that we had to make sure that we enhance our operational response at Dover, the presence and the capability as well. So obviously, if you think about training, it’s a really important element of my role; still is, obviously. But, obviously, operational aspects of my role took priority at the time to fill in those gaps, up until the point where we had that increased headcount at Dover and that further capability in training.
Q. Understood. I want to talk first about your role in developing policies. You weren’t involved in the original drafting of the specific small boat policies; is that right?
A. So looking into some of the evidence I’ve seen as part of my evidence proposal and some of the SOPs, I’d say that is correct. I wasn’t directly involved in their creation, but I was fully aware of the intention of those documents and I had, you know, visibility of those SOPs and policies prior to their official —
Q. You were aware of —
A. — publication.
Q. You hadn’t developed them yourself.
A. No, I hadn’t developed them myself, no.
Q. Let’s just put them on screen so we are sure what we are talking about. So paragraph 26 of your statement, please. 9632 is the Inquiry number {INQ009632/12}. We see there you’ve listed three policies in force as at 24 November 2021. Is that what you are talking about?
A. Yes, if I am thinking about the documents, yes, as I remember them, yes.
Q. Did every policy that would have been — or every iteration of the policy that would have been published after your appointment in August 2021, would that have had your stamp on it, your input, or have you been telling us that your heavy involvement in operational detail in those initial months meant you weren’t perhaps heavily involved in policy development at that time?
A. I wasn’t heavily involved in policy development at that time, but as I mentioned, I had visibility of those policies and SOPs. Obviously, as part of my role, again, policy is quite big — a big part of my role and at the time, I was — I was starting to have that aspect of my role being developed by speaking directly to our maritime policy lead, again a single point of contact managing all of the maritime policies, including obviously small boats at the time as well, and with senior officers as well to make sure that I had a view and clear understanding of the policies because obviously, as part of my role, I needed to make sure that those policies and SOPs were applied as well.
Q. Yes.
A. So yes, I was aware of them. I did understand them, but I wasn’t directly involved in their drafting and creation.
Q. Has that changed since?
A. It has changed significantly. Now you could say that policy potentially has my stamp in a sense that, again, I am not the maritime policy lead, but I am working quite closely with our maritime policy lead to take advantage of their knowledge and skills. I’ve developed my skills, as well my policy creation skills, let’s say, and drafting skills to make sure that everything and anything we publish and create is appropriate as well.
Q. And since you stopped being operational in 2023, has that policy and training element of your role become even more important or even more —
A. It has become even more important. It’s always been important, but I have been focusing on it much more and I have had the time to focus and develop it as well, whether we are talking about training or continuous development on watch — on watch training policy as well.
Q. Let’s just look at that second SOP on the list there, which is {INQ000428/1}, the one called “Incidents Involving Migrants”. Page 1 says when this should be used; when a report of potential or confirmed migrant activity is received. And then page 2, if we could turn to that, please {INQ000428/2}, just above the heading “Distress Phase”, it says: “All migrant vessels in the UK SRR are in grave or imminent danger until credible evidence suggests a distress response is not needed.” That, as I understand it, is HM Coastguard’s policy on small boats that are within UK waters; that all of them are classified as distress until otherwise — until credible evidence is received that it’s not needed. Is that — that’s your understanding?
A. Correct, yes.
Q. Can you explain the reasoning behind the policy?
A. Again, at the time, I wasn’t part of, you know, creating and publishing that guidance and policy —
Q. Does it remain HM Coastguard’s policy?
A. Correct. It only makes sense that it remains a policy. Again, if you look into small boat crossing incidents and the nature of notification, so initial information received that — the people on those boats are not mariners. They are desperate. They want to be rescued as soon as possible, especially as soon as they cross into UK search and rescue region, because their intention is to cross into the UK search and rescue region. So it only makes sense that we treat those reports and incidents as being in distress unless, ideally, we have that credible information from reliable assets, so our assets or Border Force assets or even French coastguard assets, to indicate that grave and imminent danger is not present as part of the distress, which means it still requires search and rescue response and timely response and adequate response anyways, but when we are dealing with multiple incidents, we need to know what the priority is, because if — and that’s the difficulty with being part of a search and rescue authority. Our training as coastguards is, you know, we need to take information, validate that information, analyse the information and be able to task the right asset to do the right thing at the right time. And with the volume of small boat incidents and crossings, that kind of prioritisation of search and rescue response has become even more evident. It’s different from dealing with a fishing vessel sinking. We will throw everything and anything to this incident as required, but we are talking about a single incident. When you are looking into multiple reports, and distress incidents, it’s — ideally, you want that enhancing information, that reliable information and credible evidence to be able to prioritise the response as well. But if not, we are covered in the sense that it’s still distress. We can’t change that, so we will treat it as distress and task the resources that we need to task.
Q. Throw everything at it like the fishing vessel or slightly different?
A. Well, again, it depends on the information we have, how big the vessel is, how much persons on board there is; a plethora of information we have to attempt to gather/assess. So whatever I say, it won’t be valid because I can’t speak for every different —
Q. Each case is different?
A. — type of crossings and — correct.
Q. Yes. Let’s look at your role and training. We can take that down now. Thank you. When did you first become involved in training for small boats?
A. I can’t really give you a date or a timeframe, but I do remember roughly. I would say it was definitely within 2022 at that point when I started delivering some training in the sense of, for example, going to the JRCC and providing some training in the form of a presentation, Q&A and discussion with the teams there, but online sessions as well. I wouldn’t necessarily class it as training, but it was part of continuous development to make sure that we enhance our operational capability at the time.
Q. And do you recall, prior to your appointment in 2021, had there been training on small boats? Not by you, but from others, presumably.
A. There was definitely some form of training and development being — going around as part, for example, of small boats, around termination of search and rescue as well, if you look at the Operation Sommen to make sure —
Q. I will come on to that in a minute.
A. — yes, we have a clear understanding.
Q. Let me show you this first. So it is {INQ008914/1}. Do you recognise these training slides? They are dated 17 August 2021, so just a day after you were appointed, not your name on them.
A. If you just go through some further slides, I will be able to answer the question.
Q. So they are not very long, but they essentially —
A. Yes, I do remember this, yes.
Q. Do you know who this training was given to?
A. It was definitely given to everyone at Dover MRCC, as far as I can recall.
Q. The Inquiry has heard evidence from several HM Coastguard staff at Dover that they don’t recall attending any small boat training before November 2021. Do you know why that might be?
A. I wouldn’t be able to answer that really because, again, delivery of training wasn’t my priority and focus at the time. It was the operational aspect of it. So things in relation to training and development were still kind of managed between the MRCC commander at the time and the clandestine operations liaison officer as well and the other on-station SEO management and managers as well. So it was a joint effort at the time and that was something that I would like to say was led by the MRCC commander at the time with me potentially starting picking up later on some elements of it.
Q. Also in relation to training, let me show you {INQ003294/1}. So we can see here this is an email from then deputy chief coastguard division 4 network commander, Helen McCaffery, to a number of Border Force and HM Coastguard staff, including you. We see your name on the distribution list. It is setting up a meeting on 13 August 2021 to, as she says in the email, as we see there towards the bottom of the page: “… to ensure that [HM Coastguard] and [Border Force] maintain a dovetailed approach to training in preparation for implementing the small boat protocols and SoPs in September.” You have already referred to Operation Sommen. Is that — the small boat protocols and SOPs, is that referring to Operation Sommen, the go-live date?
A. I wouldn’t be able to answer that question based on this email, really, whether the intention was to deliver training due to Operation Sommen coming into effect.
Q. When she is talking about implementing the small boat protocols and SOPs, what do you understand those to refer to?
A. As I read this, training to support small boat crossings at the time, and like I have mentioned, training and development and policy making at the time was not something I was directly involved. So Helen, for example, was one of those people that were directly involved in pushing forward that training and development and appropriate meetings as well at the time.
Q. And were you aware of training around Operation Sommen in summer and August?
A. I was aware of it, yes.
Q. Would it be fair to say that that was the focus of training around that time, summer/autumn 2021?
A. I wouldn’t be able or confident to answer that question whether that was the priority for delivering training at the time, but it was definitely one of the priorities because we had to clearly agree on the protocols of terminating search and rescue. In order to proceed into the Op Sommen internal tactics, we had to be confident as a search and rescue authority that we had enough reassurances to pass over that responsibility and co-ordination back to Border Force maritime, so it was definitely one of the priorities.
Q. Finally on training, the Inquiry has heard evidence last week from a MOO at Dover that there was no formal training on small boats when he joined in March 2021. He referred to several what he called standard practices that happened at Dover that maybe weren’t in standard operating procedures or policies, but apparently everyone did. So one example of these is telling callers from small boats to hang up and dial 999 to try and get a position in that way; telling callers if they were not connecting to UK 999 calls, they were still in French waters. Were you aware of either or both of these, what he called standard practices?
A. Well, as I mentioned, I was by that time — at that time, I was a team leader at Dover. Again, just to give a bit of a background, I was initially a single maritime operations officer, an SMC, at the JRCC at the time. So one of the difficulties as well was — with me taking up a promotion as a team leader at Dover meant that I was still kind of trying to understand what the small boats crossings search and rescue meant and how I could best respond as an SMC and team leader to those search and rescue operations. So there were standard actions and procedures we followed as part of being a learning organisation, search and rescue authority, of doing whilst the operations were live. Yes, some of them, if not all of them, were not part of a standard operation procedure, but because those operations were led, one way or another, by Dover, we knew how we were — you know, it was most appropriate to deal with those instances. And obviously, again, we and senior leadership was in the process of trying to collect the information, understand the information, how and what we do operationally and whether that was appropriate at that tactical and statistical level when we are trying to create SOPs and training. So things were changing. Some of the things were actually good practice and up until today are part of our policy and standard operation procedures as well.
Q. So is it fair to say that things on the ground essentially moved too fast for the procedures or things were going more quickly on the operating room’s floor than the procedures could catch up with?
A. Again, I wouldn’t be confident in saying this because I wasn’t 100% sure how senior leadership and our policy area of work was dealing with small boats at the time, especially if we are talking about March 2021. I am not sure whether we are trying to catch up or whether we’re still in the process of prioritising guidance at the highest strategic level and then moving downwards towards the operational level to make sure what makes sense strategically and within policy is appropriate to filter through down to operational.
SIR ROSS CRANSTON: But what about those two specific points that Ms Moffatt put to you; “Call 999, don’t hang up on 999”. Did you know about those?
A. So are you referring to, let’s say, the — if you ring 999 and we can’t get a position, ring again to try and —
MS MOFFATT: So the first one was telling a caller to hang up the call and to dial 999. That might give a position, for example.
A. That is, I can only assume, in case they haven’t rang 999, but we got the call through another emergency service. So, again, we will attempt — again, because there were no specific operational procedures at the time and I can only speak for myself if we are talking about March 2021, if we are talking about that kind of timeframe —
Q. March-November 2021.
A. So we will endeavour, as far as I understand, and in my role as a tactical lead at the time — it’s our responsibility to get as much information as we can before going down the route of, “Hang up now and call 999”. So we will attempt — because, as you know, maintaining a call connection is really difficult in the Channel, so I will expect everyone to gather as much information as possible whilst that call is active, even if it means asking questions like, “What can you see around you? Any vessels?” Anything that can assist us in locating the vessel.
Q. Giving a WhatsApp number, for example —
A. Exactly, giving WhatsApp.
Q. — to get a location that way.
A. And, again, it was really difficult. We got — it was not unusual to be provided with a number and that number was invalid, for example, or wasn’t available on the WhatsApp platform. But I will have expected to gather any information possible prior to making the decision to ask the caller to hang up and call 999, because I wouldn’t be confident that that 999 call will come after that call was hung up.
Q. Because you didn’t always get a position from a 999 call because —
A. Exactly.
Q. — of where they were in the Channel.
A. So it was a consideration for the SMC and anyone being — supervising those operations to potentially consider and ask for.
Q. Just the other point just to close that off then, telling callers that because they weren’t connecting to a UK 999 network, they weren’t in UK waters, is that something that you told callers from small boats?
A. Personally, no, it’s not something I will have been instructing someone to do. It is a consideration and potentially for something to pass co-ordination over to the French coastguard, but, again, as part of either agency and, you know, cross search and rescue co-operation, I will have expected for us to gather again any information we can gather in order to assist the French authorities with a response; if we were able to get a rough position or a definite position of that vessel and it was still within French search and rescue region, for example, or French waters. It will have been our priority to plan for a response, a UK response, but the French, as a co-ordinating authority, they will have to take primacy and co-ordination of this incident and make sure that they are content with what we have planned and whether they would like us to proceed and assist.
Q. And connecting to or not connecting to a UK 999 network, would that be a reliable indicator of geographical location, in your view?
A. Based on my understanding and training, I wouldn’t say that I would be 100% confident to take that as a definite factor, no.
MS MOFFATT: Sir, I don’t know if it’s a good time now to have a break. It is 11 o’clock.
SIR ROSS CRANSTON: Yes, sorry, it is. Let’s have 10 minutes. (11.01 am) (A short break) (11.11 am)
SIR ROSS CRANSTON: Yes, Ms Moffatt.
MS MOFFATT: Before I move on to communication with small boats, I just want to pick up on something that you said this morning. What I understood you to be saying was that from data at the time, your view was that most small boats would cross the median line into UK waters in the morning, so in your morning shift, essentially, after 7.30 am; is that right?
A. Yes, that’s my understanding and opinion at the time, yes.
Q. The Inquiry heard evidence from Dominic Golden, who was the aerial tactical commander at the time in November 2021, and he said that he was working on an assumption that data showed that it was around 3.00 am that small boats would cross the median line. Are you able to explain why there was a difference in views as to when small boats were due to pass?
A. I wouldn’t be able to explain. I explain that — I mean, it might be that, thinking now how the — and it hasn’t changed that much, I think, but definitely the crossings will have started around that time —
Q. Around?
A. If you look at the — around 3 o’clock in the morning, 2 o’clock in the morning, yes. But obviously, those fluctuate depending the season, the tides, the weather as well, and the risk appetite from the facilitators on the French side, when they want to send the boats over.
Q. Let’s move on to communication with small boats, then. So the Inquiry has heard about the difficulties in communicating with those on board small boats, and I want to discuss some of these with you. First, language problems. Would it be right to say that there were frequently difficulties in — with the language barrier communicating with those on board small boats?
A. Yes, definitely the language barriers was one and it still is, in a lesser degree, a difficulty we were faced — faced with. That was not only because it was quite difficult for the people on board to understand what we were asking them, but also what they were saying back to us, quite difficult. We did have and we still have a capability to mitigate that language barrier which is — it’s been discussed — LanguageLine. Whether it was the best method at the time to deal with this, that is questionable and dependent on each incident and how long we could maintain that caller on the other side of the phone as well in order to activate that capability through LanguageLine.
Q. We have heard about the difficulties of calls cutting off. Despite that, did you and your team use LanguageLine in November 2021?
A. I can’t remember personally if I have used that —
Q. You can or can’t, sorry?
A. Sorry?
Q. You can or you can’t?
A. I cannot.
Q. You cannot.
A. I cannot remember whether I have used the capability, but I was fully aware and confident and trained to utilise that.
Q. I want to also ask you about whether you recollect a proposal for a temporary migrant operations telephone operator role for Dover in late 2021. Do you remember that?
A. Yes, I do remember that. I wasn’t part of making the decision for that capability in my role at the time. I was — I was aware of the intention from certain senior officers to — to implement that capability.
Q. Was this someone who was a dedicated telephone operator for any small boat calls? Was that the aim?
A. In essence, the expectation was to train people up to the required standard to take 999 calls. Whether they are, you know, small boat crossing-related or not, you wouldn’t be able to filter through that 999 call if you are logged into, you know, the Dover search and rescue zones. If there is a 999 call, you would answer that 999 call. But the focus was on answering and collecting, gathering the data and the information from a 999 call, but also focusing on small boat crossings calls.
Q. So this was someone who has had specific training potentially to answer calls from small boats?
A. Any — they were able to answer any 999 call —
Q. Yes.
A. — and gather the information they required, with a particular focus to small boat crossings.
Q. And do you know what the reasons were for this proposal?
A. Again, it was — I believe one of the reasons or the main reason for going the route — down the route of the emergency call handlers was to mitigate that staffing — the staffing issues we had at Dover and the lack of trained operators in order to physically be present at Dover to answer 999 calls and gather information in order to enable the SMC and the team leaders to decide on the appropriate response.
Q. So from what you are saying, it suggests that you’re saying it was more another pair of hands rather than suggesting perhaps that people at Dover needed help with how they answered 999 calls to small boats.
A. Yes, I do not believe that one of the reasons of implementing that function was that there was lack of confidence or we weren’t having the required standard to answer those 999 calls. I don’t believe that was a consideration whatsoever for that capability.
Q. Do you recall what happened to the proposal? Did it go ahead or —
A. Yes, it did go ahead. I did play some part in its development and implementation, but it was mainly our technical training department coming up with the appropriate training for that really specific role to make sure that they’re fully trained and capable in answering any 999 calls.
Q. And this will be someone with a communications ticket, as it’s been described, presumably.
A. In essence, yes, but just focusing on 999 calls, not necessarily VHF.
Q. Do you still have that in place in Dover?
A. No.
Q. And why was it stopped?
A. It was stopped, as far as I understand, because we have reached that stage where we were confident in our staffing levels at Dover and, again, there is always two sides on a coin. At that point, given the training and staffing we had at Dover, that extra additional function wasn’t necessary at this stage and had nothing more to offer.
Q. I want to turn now to talk about the evidence the Inquiry has heard about exaggeration from callers from small boats, both from you in your statement and also others in their oral evidence. Would you agree that a belief that callers from small boats would exaggerate was one that was generally held within HM Coastguard in 2021?
A. Yes, that’s correct.
Q. The Inquiry has heard evidence from those working on the frontline with small boats that exaggeration happened nine times out of ten, almost every call. Is that your understanding?
A. Well, personally I wouldn’t be able to say nine out of ten or put a percentage to it, but it was not uncommon to subsequently, after search and rescue operation has concluded and given the evidence we have had from the assets that recovered and rescued a specific vessel and its occupants, that, you know, the follow-up information potentially — not potentially; indicated that some of the information the caller has provided us with was incorrect, especially around, you know, the status of the vessel or even, you know, any medical requirements of any of the casualties that we have recovered.
Q. And in terms of the difficulties around reconciliation — so you send a boat out to find small boat A, but you find small boat B. Small boat A has said that it’s got women and children on board and small boat B just has men. Could that not account for some of the exaggeration?
A. So, again, we will take everything into consideration. Again, I can’t talk — I can’t say what the overall best practice was, but we will take everything into account. So, again, ideally, we will have had a phone number, so we will be able to call that number back and see if someone we have rescued — that phone number actually rings, or if we had the name of the caller, ask for the Border Force crews or the RNLI crews whilst having the crews on board to check from that specific name and whether they called 999. Again, it depends on how busy it is on the day. If we had one or two small boats that we were aware of being out in the water and we recovered two, for example, again, there will have been some form of consideration around these prior to potentially saying that there has been an element of exaggeration, we are confident that it is coming from this incident, this specific vessel, and based on those grounds, potentially we are not looking for anything else. But, again, it depends on aerial coverage, which — again, everyone has highlighted how important it is in creating that nighttime picture where we can actually say with confidence that there is only two small boats there. “We have recovered two small boats. Yes, we do have, for example, five incidents open, but there is elements between all those incidents to indicate that there is — has been a level of exaggeration, if it was present, or other factors to kind of close down incidents as duplicates, for example.”
Q. So you rely on the aerial coverage to —
A. Ideally —
Q. — mitigate the problems around reconciliation?
A. Ideally, we rely on that and, obviously, information as well from the French coastguard.
Q. The Inquiry has heard evidence that it sounded as if small boat callers were reading a script, presumably from organised criminal groups. Did you also consider or was it considered that these people, not being mariners, being on overcrowded and unseaworthy vessels, may also have a genuine subjective fear?
A. Yes. Again, it’s quite personal how you perceive, for example, a danger and how grave that danger is. For someone who is not a mariner, just waves splashing over — over the sponson and water coming in, for them, it might be that they believe that they are sinking. Again, that was and still is part of consideration when we are responding to incidents and we can’t not consider that type of information, but it’s definitely part and was part of the consideration towards our response at the time.
Q. The language barrier as well, presumably.
A. Language barrier as well, one of those. Again, we are not — we are an emergency service, so we need to respond in a timely manner. So we have only got so much time to assess the information, but the safety — let’s say our safety is the fact that we will treat everything as distress unless we have information to indicate otherwise.
Q. (Overspeaking) the policy. In your statement, you address HM Coastguard’s response to exaggeration. I am just going to read out what you say. You say {INQ009632/21}: “It is not the role of the [HM Coastguard] to investigate the truth of what is being said, and our operatives do not seek to do so. The concept of exaggeration forms no part of our assessment in relation to any emergency call received, be that from a potential migrant or any other person in distress.” To me, it sounds like there is a cognitive dissonance there. You believe that a small boat is, nine times out of ten — let’s say the frontline operator believes that nine times out of ten, a small boat is in less danger than claimed, but you have to ignore that belief for the purposes of your job and treat all the information at face value. Would you agree that it is something which is cognitively difficult to do on a daily basis?
A. Based on the training every single operational staff receives within HMCG and the nature of our work, I wouldn’t say personally that is, you know, a challenge. At the end of the day, we are there to do a job and quite significant job, which is to save people’s lives. So we will take any personal assessments and beliefs even if we know it’s quite common for exaggeration to be part of it, but we will not — yes, we will not make decisions based on that belief, even though it is quite widely known that such exists. So based on our training and our overall behaviour and, you know, attitude and professional development within the coastguard —
Q. It’s not difficult —
A. — I don’t think it’s difficult.
Q. To your knowledge, did HM Coastguard, perhaps also including you in your role as the small boat tactical commander, ever consider the potential impacts of this very widely held belief on the decision-making operatives or potentially whether it could negatively impact on search and rescue response?
A. I think it was identified. I can’t remember, but there was some training around bias as well that was delivered within coastguard.
Q. Let’s look at that. I think it might be what I am about to show you. So {INQ000362/1}, please. So these are training slides from June 2021. The title is “Confirmation Bias & Human Factors”. Is that what you are referring to?
A. Yes.
Q. So you have seen these previously?
A. Yes.
Q. And have you taken this training?
A. Going through the slides, I can definitely — they definitely look familiar to me.
Q. We can just flick through so you can just take a view and look at them. To me, it doesn’t suggest that — we can keep going, if that’s okay. It doesn’t suggest to me, looking at the content of these slides, that they were tailored to small boats; is that fair to say?
A. It was tailored for search and rescue operations, which — small boats is search and rescue.
Q. So generic search and rescue?
A. Search and rescue. I wouldn’t agree with the term “generic”.
Q. Search and rescue?
A. Yes.
Q. If we could then just go to page 3 {INQ000362/3} of the slides, so it says there: “… the tendency for appraisers …” It’s defining what confirmation bias is: “… to believe something and search for confirmation of what they already believe. When appraisers jump to premature conclusions, or are biased in a certain direction, they do not wait until all the pertinent market facts have been gathered and objectively analyzed. They try to interpret everything to justify their conclusions.” So as far as you are able to say, why — what particular reasons did HM Coastguard identify for needing this training on confirmation bias?
A. I wouldn’t be able to answer that question because I wasn’t part of making the decision for this training or any shape or form, I wasn’t involved in this training.
Q. And in relation to small boats, do you think there was a potential problem around this cognitive dissonance, as I have called it, between believing that small boats are exaggerating and also needing to treat them as in distress? Do you think that training was needed on confirmation bias in relation to that?
A. Yes, my personal opinion is based on that information that, yes, training on confirmation bias would have been highly beneficial, recognising the fact that, you know, we don’t want to reach the conclusions because, for example, it has been confirmed we followed up — follow up evidence that exaggeration was quite common in relation to small boat crossings.
Q. So would it be fair to say that or would you consider that believing nine times out of ten that a small boat would exaggerate could cause operators on the frontline to, using the words here on this slide, jump to premature conclusions or be biased in certain directions?
A. It will have — definitely be a risk, yes.
Q. And this, as you said, is the slides relating to search and rescue. You don’t want me to call it generic search and rescue, but not specifically tailored to small boats. Do you think that in the role that you had in 2021, or that you were developing, it would have been useful to have had specific confirmation bias training in relation to exaggeration from small boat callers?
A. At the time around November, personally I wouldn’t have said that it will have been critical to have that training, again, because of the training we have by default is to take everything to face value and not — it’s not for us to make assumptions and potentially think about considering downgrading the response to a search and rescue incident unless we have that credible information. So based on our training, no one will have taken that kind of risk to downgrade an incident potentially, not plan for the appropriate search and rescue response based on the actual facts.
Q. You need to have the credible evidence or the reliable evidence —
A. Exactly, and that is a big, big part of our training at all levels, especially mission co-ordinator and above as well.
Q. Let’s come back to the idea of reliable evidence and what that means in a minute, but insofar as you know, who would have taken this training? Would it have been everyone at Dover, for example?
A. Well, looking at the training slides, I will have presumed that it will have been a training rolled out to everyone or at least Dover and flank station as well, so that will have been Humber and JRCC, if the focus was around small boats.
Q. So the slides don’t suggest a focus around small boats?
A. No, they don’t. They do not.
Q. They don’t?
A. So I will have expected that to have been an on watch training for —
Q. I’m sorry, I missed that.
A. I would expect, based on the contents of this presentation, for this training to have been an on watch training —
Q. On watch?
A. — to everyone, yes.
Q. Everyone within coastguard network?
A. Operational staff, yes.
Q. Okay. Thank you. We can take that down now, please. Now, before I turn to your role on 24 November, I want to look at the HM Coastguard tracker. You know what I am talking about?
A. Yes.
Q. Yes. So the Inquiry has heard significant evidence about the coastguard tracker and that shortly before 23 November, Border Force gained access. Is that your understanding?
A. That’s my understanding based on some of the evidence I’ve seen, yes.
Q. Yes. Let’s call that up. So {INQ010650/1}, please. This is an email from someone at HM Coastguard to a number of Home Office and coastguard recipients, including you, confirming that Border Force, including the MCC, have access. We can see the date there, 22 November. When they gained access, was it your understanding that they could amend and update the tracker or that it was a read-only access?
A. I can’t say for definite because I believe at the time, it was the MRCC commander that initiated actions with granting access to partner agencies like Border Force maritime and the JCR, which, again, I later picked up on to make sure — to ensure that continuity of access and guidance as well subsequently.
Q. What was the aim of them gaining access?
A. The aim of them was to have access and able to amend specific columns and areas within that spreadsheet.
Q. So would it be fair to say that if they were given read-only access, it would be defeating the purpose of granting access?
A. Not necessarily. It would have still benefited them because they will have — they will have had access, read access, to the initial information of creating small boat crossing incidents. You go through every single line.
Q. It wouldn’t need to be emailed across.
A. Exactly.
Q. So there would be a benefit, but not the full benefit.
A. Yes, exactly.
Q. Let’s put on the screen then an email from James Crane from 26 November. This is {INQ003735/1}. This is an email you have probably seen in preparing your statement when he discusses the events of 24 November 2021. We can see there the date. It’s actually your response to him at the top. So let’s go down on to page 3 {INQ003735/3}, please, where we can see his point (3). Perhaps we can zoom in on that. I am not sure we can. There we go. So middle of page 3, see his point (3) there, where he says: “This is really a minor point …” So he says: “… a minor point and strictly operationally relevant, but the Home Office now have got access to the shared migrant tracker, and it was my understanding that they would be filling in statistics and numbers for us. This was not done and left us asking questions about ‘M’ numbers and incident feedback, as well as final numbers.” Then let’s just quickly look at your response which is actually on page 1, later on the same day, 26 November {INQ003735/1}. So you see your response to his point (3) there in the middle: “We are holding a meeting today to clarify who is responsible for completing which sections in the tracker. An email will be sent out to confirm the outcome.” So from this, we know that as at 24 November, Border Force had access, but there had been no clarification as to what they should be filling in; correct?
A. Apparently so.
Q. Then let’s look at an email you sent next day, 27 September. This is {INQ010346/1}, please, and you can see this is an email from you on 27 November to a mixture of HM Coastguard and Home Office and Border Force recipients. Can you see towards the middle/bottom of the page the heading: “Which agency is populating what sections and when?”
A. Mm-hm.
Q. And under that heading, we can see that Border Force were supposed to fill in the black section, which you say includes the UKBF ref column, column G. It might just help to look at an example of that so we can actually see what we are talking about it, so let’s look at {INQ006843/1}, please. It is going to take a little minute to bring this up. This is an iteration of the tracker, when it comes up, at 9.09 on 24 November. So if we just scroll to the right, we can see those black sections. Is that what you are referring to?
A. Based on the email, yes, including the UK Border Force reference.
Q. Let’s scroll back. Thank you. Column G we can see there. Column G, “UKBF Ref”. So that was also what Border Force was meant to be filling in; is that right?
A. As per my email instruction, yes.
Q. So one column in the coastguard section and then all the Border Force column, yes. Just pausing there, coastguard was responsible for determining to which incident a small boat that had been located was attributed, so which phonetic alphabet incident the M number would be attributed to; is that right?
A. So we wouldn’t decide — so just to clarify, if there was a specific incident, let’s say Bravo, and we had confirmation of Border Force assets being tasked to that incident, then it was Border Force’s responsibility to issue their own reference, which is the M number.
Q. Correct, yes.
A. Yes, and their own responsibility as well was to input that M number within the tracker.
Q. But they would need to know from you which was the incident — which was the coastguard incident to put — which row to put it in.
A. Correct, yes, and one indication will have been by us telling them which incident we required this asset to proceed to, and also it will have been another indication on the tracker itself by inputting the assets, for example Valiant, under incident Bravo. So that that was an instant indication, I want to believe, for — that Border Force had access to this tracker that — yes, an additional confirmation is that they were talking about this incident, as per telephone conversation, for example.
Q. So whilst Border Force was meant to be adding/inputting the information manually, would it be fair to say that they would need to liaise with coastguard in order to understand which row they were adding it to, which incident it was allocated to?
A. They would have to be aware of which incident we were requesting specific Border Force assets to be tasked to.
Q. And not only that, because, as you can appreciate, if a Border Force asset is tasked to a specific incident, it may in fact locate another incident.
A. Correct.
Q. And then you can imagine how there would be scope for errors if Border Force were not in contact with coastguard, who would be ultimately the entity who would be deciding which incident this boat related to.
A. Correct.
Q. Let’s turn now to your role on 24 November. So we can take that tracker down. Thank you. So I understand that you worked the day shifts both of 23 November and 24 November.
A. Well, based on the watch bill information I can see, that’s correct.
Q. And you weren’t there on night shift of the 23rd to 24 November, but you would have been on-call.
A. Correct.
Q. I just want to look at the Operation Deveran weather assessment from 23 November, so this is {INQ000150/1}. It is quite hard to see, but if we can just try to look at that column which says “Date and time”, I just want to understand the timings of the assessment. The “Date and time” column, I am not sure you can work that out, but can you see it? It seems to be suggesting a period of time for a block of eight hours at a go, so 22.00 hours on 23 November to 06.00 hours on the 24th, so nighttime essentially.
A. Mm-hm.
Q. And that was the amber rating at the top there. And then we can see the same block of time for the next day, 22.00 hours until 06.00 hours, again nighttime, and that was a red day or red rating. That was a red night, essentially. So where is the rating for the daytime of 23 and 24 November, so essentially, a timeframe between 06.00 hours and 22.00 hours on the 24th? Because that would have been the day shift you worked, wouldn’t it?
A. Yes, it will have been. Well, I can’t answer that question because that’s a — that’s a Home Office product, working with the Met Office to produce this. So from looking at this, my understanding was they were purely focusing on the assessment and the condition of the French beaches for launches.
Q. I see.
A. So if — when I am reading this, from 10 o’clock to 6 o’clock in the morning, in the assessment, you can see again it is more enhanced information at the top indicating small boat launch condition at midnight. So the colouring and the assessment is summarised in front of us based on looking at the midnight at 00 UTC and the actual coastal area of the French beaches or western, central and northeast beaches. So obviously, that assessment is how favourable it is for small boats to launch from the French coast. Hence why I have mentioned the fact that when we get busy from our side, from UK search and rescue perspective, it is later on the day when those boats have transited for like between four, six or even eight hours or even longer than that, depending on where from they launched, that’s when we get busy, which most likely is during daylight hours.
Q. I suppose I am trying to work out why coastguard — I appreciate this is a Border Force document, but why did HM Coastguard identify the 24th daytime as a red day whereas it looks here — well, there is no box for that time period and the red day only starts at 10.00 pm on the 24th, if you are looking at the times here. Are you able to explain that?
A. Well, I can only presume that because we know it’s really favourable, let’s say — well, it is really favourable and there is high risk of launches. That means that it will be a busy day from our perspective. So the easiest way to put it down is that it is going to be a red day for us from search and rescue perspective and response and planning. So it’s us interpreting — interpreting that and understanding that data and how that data we can take forward from our perspective to plan accordingly —
Q. I see, so coastguard —
A. — and that was the overall general understanding and consensus at the time as well.
Q. So coastguard used the Border Force or Met Office table and then created its own rating for the days that didn’t cover the time periods?
A. Yes, aligned with that information there —
Q. Aligned with that.
A. — and that’s one of the reasons that it has changed since then as well. This product is completely different if you look at it nowadays.
Q. On the evening of 23 November, the SMC at Dover, Neal Gibson, called the maritime tactical commander who was on duty, David Jones, and asked if you were around that night and David Jones said, “Give him [you] a call”.
A. (Nods).
Q. Do you recall speaking to Neal Gibson at the start of that shift?
A. No, I can’t recall being paged or called.
Q. Is it fair to say that in an ideal world, Neal Gibson would have wanted you there during that shift?
A. I think in an ideal world, based on the evidence I’ve seen, I will have expected to be contacted. Now, whether it was feasible for me — given my working hours around that time of the night, whether it was feasible — you know, feasible and safe for me to have an earlier start, it is another matter, but I will have expected at least to have a conversation and understanding around it.
Q. With David Jones, perhaps?
A. It will have been an agreement between themselves who is going to do — who is going to make the call, but from the moment that they were both in agreement or at least, you know, their intention was for me to be contacted, it will have made the difference.
Q. The — are you aware that each version of the tracker has a — well, it is a SharePoint index, essentially —
A. Yes, I am aware.
Q. — which lists the change author of each iteration and also a time.
A. (Nods).
Q. This shows that you made a change to the tracker at 1.00 am on the night.
A. Yes.
Q. Do you recall doing that or do you have any recollection of that now?
A. No, I can’t recall. Given the fact that I was resting to come in for a 7.30 start — well, it will have been me logged in and ready to go earlier than 7.30 anyways — I can’t imagine why I will have been awake going through the tracker 1 o’clock, so I am unable to recall really me going on the tracker at that time. In hindsight, it wouldn’t have made sense for me to be awake at this time of the night.
Q. Now, in terms of the operational situation at the start of your shift, you say — and let’s turn up your statement, please, actually now, so {INQ009632/16}, paragraph 38. So we see there you say: “I do recall that whilst there were some open incidents, there were no concerns, focus on any outstanding boats, or any Mayday Relays, as these would have been specifically mentioned (Mayday relays are the highest priority). I reviewed the on-going SAR plans and did not have any concerns.” We know that incidents that had been identified as embarked by Border Force asset were still open at the start of your shift. Was that normal?
A. Yes, it was common practice, especially on those really busy days, because closing down an incident completely involves some certain degree of admin, administration, purely administration behind it, which — obviously, if we are busy, we are focusing on search and rescue response, so it would have been sufficient to class or input a comment quickly within the incident stating, or even the tracker as well, that this incident has been closed, but actually within ViSION is still present, the incident itself. So it was not uncommon. It was probably more common on those busy days.
Q. And you say there was no mention of any outstanding boats or any Mayday Relay in paragraph 38, but you were aware that a Mayday Relay had been broadcast for small boats the previous night.
A. That’s correct.
Q. And the Inquiry has heard evidence that in November 2021, a Mayday Relay for a small boat was something very unusual. Do you agree with that?
A. Yes, in certain degree, I do agree. It was quite unusual to broadcast a Mayday Relay for small boat crossing incidents, unless the duty SMC had concerns regarding the safety of those people that rendered immediate response, which — obviously the Mayday Relay will assist with that immediate response in one way or another. Because it’s really important to remember if we have — had issued a distress relay, Mayday Relay, for every single open incidents, small boat incident, that is classed as distress, we would have probably created lots of issues because we have to broadcast those relays on channel 16, so we would have overwhelmed channel 16 by issuing multiple relays. Hence why we had — you have probably seen another means of broadcasting to make sure that traffic within the Channel was aware of small boat crossings, so, “Keep a sharp look out and report anything relevant to us”.
Q. The broadcast action as opposed to the Mayday Relay?
A. Correct. Again, it’s all about prioritising when we should take relevant action and making sure that we help ourselves and the casualties’ best interest of when to take specific actions, including a Mayday Relay.
Q. Would you have considered it relevant to know that whilst the Mayday Relay had been terminated, none of the small boats picked up by the Border Force asset during the night shift were in fact in a state of imminent danger or sinking?
A. So can you repeat that question again, please?
Q. So it was relevant for you to know that there was a Mayday Relay that had been broadcast presumably, or was it?
A. Given that the incident was already closed and the Mayday Relay ceased —
Q. It was open.
A. It was open, but based on the SMC’s entry, it was their belief that the small boat related to that Mayday Relay incident was one of the boats that were recovered by Valiant.
Q. When you say the SMC’s entry, are you referring to the Charlie ViSION log?
A. Yes, so that will have been the night duty SMC, Neal.
Q. And which entry are you referring to? Would it help to look at it?
A. Yes, if I recall correctly, yes, and the entry I remember.
Q. Well, let’s put the log up. So I think it is {INQ000237/1}, and let’s go down to — so if we could go down to page 11 {INQ000237/11}. So we can see there 3.50, Neal Gibson, night watch SMC: “Valiant on scene with unlit migrant vessel.” And then we get the Mike number. And then page 12 {INQ000237/12}, 4.36. See that at the top? Records: “All migrants disembarked …” Now, that’s on the Charlie log because, as I understand it from the evidence we have heard, Valiant was tasked to the Charlie, so everything that the Valiant did with any small boat would be on the Charlie log. Is that your understanding?
A. Yes, so obviously all the comments and — there has been evidence around this. If an asset is tied up to a specific incident or multiple incidents, all the entries you make within that resource will automatically be pasted into the incidents or incident they are assigned to.
Q. Then 4.45, it is recorded by Stuart Downs, the MOO at Dover on night watch, Valiant proceeding to position from the R163 helicopter, new small boat. And then 5.21: “… engaging migrant vessel …” So, again, the information about the second small boat still recorded on the Charlie log. And then 6.07, Stuart Downs, down bottom there: “Third tasking …” So Valiant is going to a third small boat in the Southwest Goodwin area. Then page 13 at the top {INQ000237/13}, 06.31, again Stuart Downs. You see the Mike number there, M959. Then 6.46, I think this might be what you are referring to when you say that the SMC had marked it as —
A. Just to clarify, yes, maybe that’s not the incident because it will have probably been one of the other ones where there was a clear statement from Neal Gibson that he believed that this is one of the small boats recovered.
Q. I think you’re referring to Incident Lima where he did —
A. Potentially, yes. So I am not seeing what I was expecting to see right now in this — this log.
Q. No.
A. Yes.
Q. In the Charlie log, I think you would agree with me there is no statement that any of these small boats are Incident Charlie. It is just recorded in there.
A. Correct, but it will have been as part of the handover, obviously, but we’ll probably come to a handover question.
Q. Yes, you weren’t — from your statement, you say you can’t recollect anything. You weren’t present at the Dover handover. You might have spoken to James Crane; is that right?
A. Correct, so the — what I can remember right now was, and I always remembered was, that there was information to indicate that there was a distress Mayday Relay in relation to one of the incidents overnight. However, the general belief and part of the handover, the understanding I had through James Crane was that we do not believe we have anything outstanding in relation to Charlie, for example, Incident Charlie.
Q. You were told there was a Mayday Relay. Would it have been relevant to have been told that, “There was a Mayday Relay, that the small boat was taking on water and need of immediate assistance, but actually, we didn’t find any small boats that were taking on water and in need of immediate assistance. The small boats we found were actually fine”? Would that have been important information for the oncoming watch?
A. My personal opinion is that it could have been handed over, the reasoning potentially for closing and ceasing the Mayday Relay. It would have potentially been useful information, but I don’t think it will have changed anything in respect to any further action or ongoing search and rescue. We rely on the SMC’s assessment, training and final decision-making. So if — a Mayday Relay has been ceased and the incident has been concluded even though it was still open within ViSION, but within the tracker, it was concluded as well, I believe based on the evidence.
Q. The tracker was open when you started your watch.
A. So Charlie was still showing as open?
Q. Open, yes.
A. Okay.
Q. Everything was showing as open.
A. But it was handed over that there was no further concerns.
Q. So it would have all been verbal —
A. The handover is always verbal and there is, as we know, an ever-changing document supporting the handover.
Q. Just going back to this, I just want to just point something out to you because 06.46, you’ll see there Stuart Downs saying that Valiant is assigned to incident 041401. That’s Incident November.
A. Okay.
Q. That’s the gen number for Incident November. And 04.46 [sic], Valiant is clear from incident 041384, that was Incident Charlie. So if you knew that it was Charlie that was being cleared from, would that have meant to you that the incident had been resolved, just that note that it was clear?
A. No, I will have expected, first of all, to be briefed on any open incidents as part of the handover anyways and I will have expected to — someone, especially the duty SMC, to go through the incident itself to confirm that within the incident, there is some formal entry or belief that this incident has been concluded.
Q. And the Mayday Relay, the fact it had been terminated, what would that have meant to you?
A. To me, it would have meant —
Q. That the incident was resolved?
A. Sorry, apologies for cutting you off there.
Q. Sorry, no, it was my fault. That the incident was resolved; would that — is that what it would have meant or …
A. It will have meant that, or potentially that the vessel will have been located and distress wasn’t the appropriate response, potentially. There was credible information to indicate a lesser degree of danger. But obviously that wasn’t the case. The belief was that the Mayday Relay was ceased because they recovered all the small boats they could recover at that time of the night.
Q. Well, just going back to where the Mayday Relay is ceased in this Charlie log, so if we could go back to page — I think it’s page 11 {INQ000237/11}. Let’s try there. So we see there an entry at 03.39 from Christopher Barnett, who was the remote SMC helping out at Dover from JRCC on the night. He says there: “No requirement for Mayday Relay …” After discussion with Neal Gibson: “… as Valiant in the area investigating targets.” So that was actually before the Valiant had come alongside any small boat. Does that surprise you, that it was terminated at that point?
A. Personally, it does. It does a little bit. I will have expected for the Mayday Relay to have been ceased at a time whereby the SMC will have had enough information to conclude that, “I believe that one of the multiple incidents — small boats recovered is — is Charlie, so on those grounds, I terminate.”
Q. So the credible information, reliable information, that wouldn’t have been it, in your view?
A. That — that’s my view, but, again, it could have been that he decided to conclude the Mayday Relay because he believed that he had sufficient resource on scene in order not to request any commercial or vessels in the area to proceed and assist because the maritime and aeronautical resource on scene was sufficient for the SMC to decide that, “I don’t need that Mayday Relay broadcast”. So that’s another mitigating factor potentially for ceasing it.
Q. Let’s just look at the SOP again, 000428 {INQ000428/1}, the incidents involving migrants again, on page 7 {INQ000428/7} of that under the heading “SAR Termination” halfway down the page. We have already talked about this in relation to credible information. This one says “reliable information”, essentially: “[Search and rescue] can be terminated where reliable information is received that the emergency no longer exists.” This might be a hard question to answer, but what does “reliable information” mean in practice?
A. Again, in practice, reliable information, first of all, I would look — the way I interpret this sentence is — for that source of information to be a reliable asset. So that will have been a search and rescue asset, maritime asset, aeronautical asset, a co-ordinating authority such as the French coastguard, someone who’s confident in the quality of that information coming through to us. Also, secondly, is the degree of confidence for that information that is passed on to us. So if that information potentially is provided to me by a passing by pleasure yacht, I wouldn’t treat it the same degree —
Q. (Overspeaking) —
A. — as if it was from a fishing vessel which I know the master and everyone on board is quite experienced mariners. So there is various factors on how much confident — how confident I would be on the level of that reliable information.
Q. What about the fact that, as a hypothetical, a sinking small boat has not been found within an initial search when you have got information that, at face value, a small boat is sinking? Would that be reliable information, an absence of evidence essentially following an aerial search?
A. Yes, it depends, again. I wasn’t there. It depends on the quality of that aerial search, what kind of search they have effected, what their belief on the quality of their search was. So what does the captain of Rescue 163, for example, think the quality of the search was? Could they see, for example, seagulls sitting on the surface of the water? Because that indicates to me they could have easily picked up people in the water or debris. So, again, it depends on the quality of the search and the quality and the confidence of the asset.
Q. So you would need to speak to the person captaining the search asset essentially to say, you know, do you think — or you need to interrogate them as to how good their search was and whether they think they could have found something that they were —
A. Yes, exactly. We need to ask for that search effectiveness, what we called, and get the information for that search effectiveness so the SMC can assess how confident they are with the searches and the quality of the searches. So as far as I am concerned, there was policy and SOPs in place back then, and still are, in relation to search effectiveness and asking for the relevant information from a search asset on scene and extract that information, interpret that information, so the SMC can make the appropriate decision.
Q. In general terms, not just related to small boat work, if the coastguard does not find a sinking vessel when it is searching for a sinking vessel, would search and rescue need to continue until the outer limits of survivability are reached?
A. That is a significant factor. It is one of the factors. Survivability, upper limits of survivability, is one of the considerations we are looking at. But, again, remember it says “upper limits of survivability”. So we know what the maximum limit is for that search, but we have other factors we need to consider that potentially will adjust the reality of it. So, for example, type of clothing, nature of the casualties, so how physically competent they are, type of LSA they have got on board. So there are other factors to consider in order to — alongside the upper limits of survivability.
Q. Yes, it is not just an outer rigid number. You have to actually factor in —
A. Exactly, and it depends on whose — you know, on the SMC. It depends on the tactical commander. It is a really thorough conversation you have to have with that SMC and tactical level in order to make a joint decision on how long we are going to keep searching for, and most likely it will involve duty strategic commander as well —
Q. But you would need to think about survivability. If you don’t find the asset you are looking for, the sinking boat —
A. It is one of the considerations and factors, upper limit of survivability, definitely.
MS MOFFATT: Sir, I don’t have that much longer. Are you happy for me to continue?
SIR ROSS CRANSTON: Yes, of course, yes.
MS MOFFATT: You started the watch as the small boat tactical commander, but due to the volume of incidents, at around 8.00 am, as I understand it, you handed back Tactical Command to the JRCC.
A. Correct.
Q. And you took on the role of a mission co-ordinator. Is that essentially similar to the MOO role?
A. In essence, yes. I wouldn’t put the title of the role, so maritime operational senior, but in my capacity as a mission co-ordinator and my competency and my training, yes, you could say — generalise it and say that, yes, at the same level of maritime operation officer or a senior maritime operation officer with no SMC qualification.
Q. I see, but you worked under James Crane as the SMC for that watch.
A. Correct. As normal practice, there is only one SMC who is responsible, hence even though I was SMC, as with Rich Cockerill, we were working under James Crane.
Q. Yes, but you say you also provided further advice and engaged in discussion as part of your day-to-day duties as the migrant SAR commander. So were you still effectively wearing two hats? Perhaps you had handed back Tactical Control for the RAG review, but you were still playing a slightly different role than a usual mission co-ordinator.
A. No, I wouldn’t say so. So what we do as a coastguard with the teams we are doing it, so operational teams, it is always a joint effort. It’s not one person’s work. It is a team effort. So any information, any, you know, experience we can take advantage of during those operations in any search and rescue operations is always beneficial to make informed decisions. So obviously me, due to the nature of my role and experience, I was able to have conversations with James Crane to support or maybe, let’s say, enhance his decision-making. So I was — it wasn’t me, let’s say, influencing his decisions. It was me providing him with all the information and knowledge I had to support his role as a duty SMC on the day.
Q. And you have said that you don’t recall taking a break on a 12-hour shift.
A. I can’t recall. It was — again, like many mentioned, on those busy days, I will have opted out with taking a break, but I was still having my comfort breaks and —
Q. Was it common in Dover in 2021 not to be taking breaks?
A. Yes, it was quite common, yes. It wasn’t encouraged whatsoever, but if people opted out for it, they will do it. But obviously, mental well-being is everyone’s consideration at the time, so even if some people wanted to keep doing what they are doing, if someone observed that was taking a toll on them, we will have been advising otherwise.
Q. So we know you handed back the Tactical Command to JRCC.
A. Correct.
Q. We know from the Charlie ViSION incident log later in the morning than the bit we looked at that it was George Close, one of the maritime tactical commanders at the JRCC, who RAG reviewed Charlie at around 10.00 am. Presumably that was why he did it and not you, because you had already handed back the Tactical Command.
A. Right.
Q. You are identified as making an amendment to the tracker at 9.09. We looked at that version, but we didn’t look at your amendment in particular, but it was marking Incidents Lima and November as resolved and James Crane had marked Incident Charlie as resolved. Are you able to say what sources of information you would have used to mark those incidents as resolved on the tracker?
A. Well, it will have been information within its — within the incident itself.
Q. Within the ViSION log?
A. Within the ViSION log, obviously, yes. So we all know ViSION log is the primary recording platform for information and response to search and rescue. So I will have looked into the ViSION logs and obviously I will have spoken to James Crane to make sure that he was aware and content with marking incidents closed, especially within the ViSION log.
Q. Because he was the SMC?
A. Correct.
Q. So it wouldn’t be — I am not talking about marking incidents as closed here. I am talking about the tracker —
A. Yes.
Q. — you know, with the “R” rather than the “O” in that column.
A. Yes, yes.
Q. Yes.
A. So yes, for example, if it was quite clear within ViSION that the incident was concluded, I wouldn’t have asked necessarily James Crane’s or the SMC’s permission to mark it as closed to the tracker because —
Q. Resolved on the tracker?
A. Resolved, yes, because we follow what’s on ViSION at that stage, at that stage of the operation. So if it’s concluded within ViSION, we will resolve it within the tracker as well.
Q. Is it possible that you could have looked at the tracker itself and seen that there were M numbers for Lima and November, for example, and as a result of that, just in and of itself, looking at the face of the tracker, put the “R” against Lima and November? Would that have been enough, the M number?
A. No. It will have been enough — again, I will have looked into the ViSION log. I wouldn’t have just closed/resolved an incident within the tracker because it has an M number. It can have an M number and the incident will still be ongoing. For example, we’ve recovered the casualties, but there is a requirement for ongoing medical attention. It could be helicopter winching, so still tasking their asset to perform a casualty extraction, for example, or render further search and rescue support. So an M number wouldn’t be a consideration or the sole factor of resolving an incident whatsoever.
Q. So would it be fair to say that it would be an unsafe action to mark something as resolved on the tracker just due to the information on the tracker itself? Would you need to always look at the ViSION logs to be sure?
A. Correct.
Q. I want to just then look at your involvement in closing incidents on 24 November. In your statement, you say that before closing incidents where telephone numbers were available, that the MOOs would be directed to call them.
A. Well, that’s what I will have expected if I was in charge —
Q. Yes.
A. — for the team, yes.
Q. And you would expect them to record it on the log if they did it?
A. Correct.
Q. The ViSION log, I mean.
A. Correct.
Q. You have told the Inquiry that to the best of your knowledge, you weren’t involved in the closure of Incident Charlie, and that’s again reflected in the ViSION log. Your name isn’t there. But you were involved in the formulation of a standard paragraph for the closure of certain incidents on the day watch.
A. Mm-hm.
Q. I just want to look at that. So {INQ010349/1}, please. This is an email chain between you and James Crane. We actually need to go to page 2 for the start of it {INQ010349/2}. So we see his email to you at 17.12: “George, “This is the generic statement I [came] up with back in August …” And you see the generic statement there at the bottom, and he says that it’s used — for use with leftover incidents. What does that mean, “leftover incidents”?
A. So to explain this, because it can be quite misleading, that wording and that classification saying “leftover incidents”. So that’s, for instance, as far as I am concerned, trying to make it a bit, you know, more professional based on the action which we are taking was, I will have expected to be incidents that are still open, unattributed and not having enough information to render any further search and rescue action from our perspective —
Q. There’s no clear specific conclusion, so it doesn’t say, for example —
A. Yes —
Q. — “embarked by the Border Force asset”.
A. Yes, there is insufficient evidence to support further search and rescue action.
Q. It sounds from this email as if this generic message wasn’t used between 21 August, when it was last used, and 24 November. Is that your understanding? Did you use a generic message in between those times?
A. I can’t really say for definite.
Q. Was 24 November the first time you used a generic message or do you not recall?
A. I can’t recall.
Q. Let’s look on page 1 {INQ010349/1}, which is your reply in the second half of the page. Effectively, you just slightly amend the text and your version is the one that’s used for the incident logs on the 24th. We see at the bottom, it says: “After the cessation of multiple migrant incidents during today. No further calls have been received for this incident or further confirmed sightings. Areas of interest have been searched with nothing untoward found. With this in mind, it is being closed pending further information.” Then we see this text being used by James Crane. Let’s just finish the email chain, so {INQ010351/1}, please. We see there an email from James Crane slightly later in the day on the 24th to some of his team members, including the trainee, who we know on the day closed lots of the incidents. He says there: “… for use on as many of the [open, it should say] migrant incidents as we can before the [end of the shift].” You say in your statement that this wasn’t a blanket application to all incidents.
A. (Nods).
Q. Would you agree that on the 24th, it in fact was used perhaps more widely than it should have been?
A. It depends on whether this — first of all, this summary, this closing statement, was at the time a considerate action. It wasn’t, let’s say, a quick way of us just closing down the incident. So we took into consideration all the information we had, because it was a number of incidents having the same kind of lack of information. So there were similarities between several unattributed open incidents, but at the time, this closing statement seemed to be the most appropriate way to justify closing down physically, doing the admin for closing down incidents as well. Again, this message highlights the importance of air surveillance and having the maritime picture. Also, if there are any further ongoing calls, 999, coming through, we will have closed open incidents because it could have been potentially one of those, but still we will have created new incidents based on 999 calls. And we also relied on the French information. So if we knew that the — and we will have most likely known that if the French coastguard had no further ongoing small boat crossing activity, again, that was another consideration to believe that there is no ongoing small boat crossings at this stage. So at the time, it seemed to be an appropriate closing statement, a considerate closing statement, for more than one unattributed open incidents.
Q. We know that it was used on Incidents Lima and November, the ones that had been embarked by the Valiant, so would you agree that those were — it was an incorrect use in relation to those incidents where there was information that those small boats had been embarked by a Border Force asset?
A. I — again, I want to believe that — you might be able to help me with this. I believe that within those two incidents, there was information from the night SMC to indicate his belief that one of the small boats recovered was part of that incident.
Q. Certainly in relation to Incident Lima, it was on the ViSION log and also in the tracker that had it been recovered by the Valiant.
A. Correct. So what will have happened on a really busy day, again, we will have looked at that information and we will have taken that at face value. So the night duty SMCs state that their belief is that incident is concluded because it might have been most likely one of the multiple vessels recovered. However, when we went through, let’s say, the end of day assessment of the incidents, we thought at the time that this closing statement was an enhancing factor for closing down those incidents even though the previous SMC’s assumption was, or belief, that the incident is concluded because we rescued that small boat. So from that perspective, in our heads, in the SMC’s head, the tactical commander was, “Listen, the SMC’s belief was this that incident is concluded, most likely related to a small boat we have rescued”, but with this additional closing statement, we have taken into consideration further searches, no further 999 calls. So it’s not us closing the incident just based on that belief. It is an additional justification. Whether it was inappropriate — I wouldn’t say inappropriate; probably incorrect because we have evolved since then and personally, I have created a specific standard operational procedure around closing unattributed incidents which is really specific, and the guidance is quite strict on this to make sure we cover all angles.
MS MOFFATT: Thank you, Mr Papadopoulos. I don’t have any further questions for you. Sir, I don’t know if you have any. Questions by SIR ROSS CRANSTON
SIR ROSS CRANSTON: I am wondering: do we have that guidance, that recent guidance?
MS MOFFATT: We can certainly request it.
SIR ROSS CRANSTON: It would be helpful if we could have that. Look, I just want to take you back to the issue of the time that the small boats or most small boats arrive in UK waters, and I am still a bit unsure about this. And I know you said it depends on the tide and the weather and, of course, there is a variation, but are you saying that they — that most of them arrive in the early morning after 5.00 am rather than 3.00 am? Is that when most of them arrive, or is it difficult it say?
A. It is difficult to say. That’s my impression as of now. It can be that it is a bit misleading because I have been doing this job for quite a while and you know —
SIR ROSS CRANSTON: I think you said there wasn’t any difference between 2021 and today.
A. There is a difference.
SIR ROSS CRANSTON: There is a difference?
A. There is a difference.
SIR ROSS CRANSTON: Ah.
A. There is certainly a difference on when we get the majority of crossings nowadays. Back in the day of 2021, they were a bit earlier than they are today, based on the data and the stats I can recollect.
SIR ROSS CRANSTON: I see.
A. But it has definitely changed, and it’s an ever-changing factor based on risk appetite, weather conditions and another factors as well.
SIR ROSS CRANSTON: Yes, yes. Well, thanks very much for your statement and also for the evidence, Mr Papadopoulos. It’s been very helpful. I understand Professor Tipton is here, so if it is convenient, we will have a 10-minute break and then continue with him. Thanks very much again.
A. Thank you. (The witness withdrew)
SIR ROSS CRANSTON: Right. (12.18 pm) (A short break) (12.29 pm)
PROFESSOR MICHAEL TIPTON (called)
SIR ROSS CRANSTON: Welcome, Professor Tipton. Thank you for your report and also the statement. Sarah Le Fevre has got some questions for you, but first of all, could you read the affirmation?
A. Yes, sir. (Witness affirmed)
SIR ROSS CRANSTON: Thank you. Yes.
Questions by MS LE FEVRE
MS LE FEVRE: Thank you very much, Chair. Mr Tipton, would you give the Inquiry your full current professional job title?
A. Professor of human and applied physiology at the extreme environments laboratory, University of Portsmouth, UK.
Q. Thank you. You have been instructed by the Inquiry to produce an expert report relating to survivability in relation to the victims and survivors of those involved in the incident of 23 and 24 November 2021, which, as you know, this Inquiry is charged with investigating; is that right?
A. That’s correct.
Q. You have produced a report on 8 December of last year in response to that question, which ran to some 32 pages.
A. Correct.
Q. Thank you. Can I turn up on our screens, please, {INQ010283/2}. At paragraph 1.1 of your report, you have set out some of your expertise and roles past and present in this field. It’s right, I think, that you have specialised in thermal physiology for some 40 years now.
A. Correct.
Q. You are widely published in this and associated areas; yes?
A. Correct.
Q. Your current roles include — is this right — you are a council member of the RNLI?
A. Yes.
Q. And a consultant adviser to the medical director of the RNLI.
A. Correct.
Q. What other relevant roles do you hold presently?
A. I have just taken over as chair of the National Water Safety Forum.
Q. Thank you. And what is that body?
A. That’s a body that was constituted in 2004 following a Government initiative to over — be the overarching body for groups trying to work in drowning prevention in the UK, so the RNLI, the coastguard, Surf Life Saving GB and lots of other organisations are all members of the National Water Safety Forum. It’s an attempt to co-ordinate and integrate the approach to drowning prevention in the UK.
Q. Thank you. And you have just taken the position as chair of that forum.
A. In November, yes.
Q. Thank you. We can take that off the screen, please. You were provided with and directed to a range of material for the purpose of preparing this report. That included the report published by the Marine Accident Investigation Branch last year; is that right?
A. That’s correct.
Q. You were directed to the accounts given by a survivor, Isa Mohammed Omar —
A. Yes.
Q. — both in writing and orally to this Inquiry on 4 March, and directed to accounts in relation to occupants of the boat, both those who are known to have died and those who remain missing following these events as well; is that right?
A. That’s correct.
Q. Thank you. You have, through your report, extracted the information relevant to your assessments and expertise from those sources of information; is that correct?
A. Correct.
Q. And those include your extraction of a timeline —
A. Yes.
Q. — of the equipment or information about the equipment with which the boat occupants were provided —
A. Correct.
Q. — the condition, insofar as could be established, of those occupants —
A. Correct.
Q. — and the weather conditions.
A. Yes.
Q. Are all those relevant to your work in assessing survivability and the questions to which you were directed?
A. Yes, they are.
Q. Thank you. Can I have on screen then, please, again Professor Tipton’s report, {INQ010283/8} at page 8, please, and (xvi). That’s the timeline you derive, I think, from the accounts of and in relation to the boat occupants. It’s very similar to the timeline extracted from the MAIB report. We can see the events begin at 21.00 on 23 November with the numbers of persons including 13 women and eight children who boarded the inflatable boat, and ends at 13.00 the following day when bodies were sighted in the water by a French fishing vessel; yes?
A. That’s correct, yes.
Q. And you have timestamped or included timestamps between those two points in time when the boat began to take on water at about 01.00, the boat, Charlie boat, reaching UKSAR at 01.30, the timing when the boat became swamped and occupants began to enter the water, and the timing of sunrise; yes?
A. Correct.
Q. Over the top of that timeline, we might insert two other timestamps that you refer to at various places in the report. Firstly, 03.24, that’s the time when the Valiant Border Force vessel arrived at a set of co-ordinates provided to it by HM Coastguard and those co-ordinates provided a little earlier that evening; yes?
A. Yes.
Q. And the timing of 07.03, that being the time when that same Valiant Border Force vessel informed HM Coastguard that it was returning to Dover.
A. Correct.
Q. Thank you. Can I look next at page 4 of this same Inquiry reference, please {INQ010283/4}, and paragraphs (xvii) and following. That’s your extraction — is this right — of information about the equipment with which those occupants of the boat were provided on 23 November? Do you see that?
A. That’s correct, yes.
Q. So you note that it had been variously reported that 14 occupants or, conversely, all occupants had been provided with life jackets.
A. Correct.
Q. The construction of the flotation devices and the level of support they provided wasn’t — hadn’t been available to the MAIB investigation; yes?
A. Correct.
Q. And that no information was available to the MAIB or otherwise as to whether any of those flotation devices had been fitted with lights.
A. Yes.
Q. Did you come to some understanding of the quality of the flotation devices that had been provided to boat occupants on that night?
A. I did, supported by subsequent statements that I’ve seen that the provision of life jackets provided were of poor quality.
Q. Thank you. Next, I want to ask you a little about the information you mined about the condition of those occupants. Can we turn to page 6 of this same document, please {INQ010283/6}, and we can see, to the foot of that page, you looked at the statements from family members to derive the information that you could derive about their experiences prior to boarding the boat; yes?
A. Correct.
Q. And their ability to swim and their build. Why are these features important to you?
A. We know that your ability to survive cold water immersion is dependent on things like your size, your body shape. Subcutaneous fat, for example, has the same thermal characteristics as cork, so it is a good insulator. People who are thin and tall will cool more quickly than people who are short, stockier and fatter. We also know that things like reduced blood sugar will impair your ability to defend your deep body temperature to a challenge of cold water, so hypoglycemia, and we also know that with, you know, fatigue and exhaust, that can also have an impact. Now, the situation in which many of the individuals found themselves prior to this particular voyage was living in a cold, wet, tented village. Many reported being hungry and cold. And then on the evening of the event, they — the voyage, they walked for two hours to get to a starting point, so that was in cold and wet conditions. So these all preset the likelihood of you being able to defend your deep body temperature and stay warm when eventually you end up in the cold water. Clearly, being a non-swimmer is an important component in that. So there were — there was nothing really in the status of individuals prior to the event that was of any help whatsoever to them in terms of surviving a cold water immersion. In fact, all of the — pretty much all of the conditions they found themselves in were going to negatively impact on their survivability.
Q. Thank you. Can we complete this section and turn to the next page of the report, to page 7 {INQ010283/7}, please. You continue with your information mining, if I can put it that way —
A. Yes.
Q. — looking to establish what people were wearing; is that right?
A. Yes.
Q. Again, the observation about life jackets and the quality of the life jackets, the general physical health of those involved; yes?
A. Yes.
Q. And then whether or not there was any reference to motion sickness having been experienced. Why was that important?
A. We know that people who become seasick cool more quickly than those that don’t, largely because they don’t actually shut down their peripheral blood flow, which is — the way the body defends against the cold is to withdraw the blood centrally to make the most of the subcutaneous fat, the fat around the skin. The other point about the clothing is that although people were wearing, in some cases, fairly heavy normal clothing, unless it’s specialist protective clothing against cold water, it pretty quickly gets swamped, saturated and offers little in the way of insulation. It would okay during the period when individuals were in air, but as soon as that air is replaced with water on immersion, the insulative value of the clothing just about disappears.
Q. Thank you. All right. Can I take you now to page 3 of the same document, please, for the information gathered about weather conditions {INQ010283/3}. It may be very obvious to you, but why is it important to you to understand what the weather conditions were?
A. Thermoneutral air temperature for a human is around about 26 to 28 degrees Celsius, and that’s somebody who is wearing very little clothing. Thermoneutral water temperature is 35 degrees Celsius. So on — at the time of this particular incident, the air temperature was 2 degrees Celsius, so there was a large gradient for cooling pre-immersion, so people may well have entered the water already pre-cooled. Against that is that the boat was crowded. People were wearing heavy clothing. Some people were working hard to try and maintain the buoyancy of the boat. So I think that’s somewhat debatable, but I suspect that some people were pre-cooled if only in the sort of extremities, which would affect things like their ability to hold on to things, to grip things, as opposed to a fall in deep body temperature where they are moving towards hypothermia. And the sea temperature, at 13 degrees Celsius, is well below thermoneutral water temperatures of 35 that I have mentioned and establishes a fairly significant gradient for heat loss. We will presumably come on to talk about some of the responses evoked by that water temperature, but cold shock, for example, would normally be at its peak in water between 10 and 15 degrees Celsius.
Q. Thank you.
A. So this was a challenging environment both in air and water.
Q. Thank you. And to complete your observations, at (iii), you comment on the sea state, and at (ii), you comment on the wind direction and force. The significance of those two factors, please?
A. We can talk about cooling according to the thermal gradient, but if you are in a sea state that is particularly severe, the chances of you drowning just simply because of, you know, the ongoing challenge to the airway of waves is fairly high. So in that situation, you would expect people to succumb very quickly simply because of the rough sea state. Where — wind adds to the wind chill factor, so it increases the convective heat loss of people sitting in air and would, as I say, increase the thermal challenge in air. Not so much in water, of course. In water, it is going to be the movement of the water which is the challenge.
Q. Thank you. The sea state at the time with which we are concerned you describe as smooth near the coast, slight offshore, so not particularly turbulent.
A. Not particularly turbulent, although there are some witness statements which talk about large waves at some stages later in the event.
Q. Thank you. All right. I am going to ask you now some questions, and you foreshadowed them already to some extent, about the physiological and pathophysiological responses to immersion in cold water, and you deal with this at part 3 of your report at page 8 and following {INQ010283/8}. If we can go to page 8, please, you say that this is ground covered by the MAIB report and that you agree with the position in the MAIB report, I think, effectively because the MAIB report is based on your own prior research; is that right?
A. That’s correct, yes.
Q. Thank you. So that’s true of this general topic of immersion?
A. Correct.
Q. Thank you. You have identified for us three relevant phases to immersion: initial or cold shock, the short-term immersion and then long-term immersion; is that right?
A. Correct.
Q. Thank you. If we pick up, please, at page 9 then {INQ010283/9} your observations about initial impression at 3.2. Thank you. This is the immediate reaction to immersion in cold water; is that right?
A. Correct.
Q. You tell us through the report that the magnitude of that reaction or shock varies and depends on a number of factors. You pick that up at page 9 in paragraph 3.2(ii). What are those factors?
A. So the cold shock response is evoked by a sudden fall in skin temperature, which would normally be at an average of about 33 degrees Celsius and very quickly becomes clamped at whatever the water temperature is, because water is very effective at taking heat away from the body. That rate of change of skin temperature evokes a dynamic response in cold receptors, which are about 0.18 mm below the surface of the skin, and that dynamic response evokes a gasp, which is between 2 and 3 litres, and then uncontrollable hyperventilation; an increase in the work of the heart, as I have already mentioned, a shutdown in blood flow to the extremities in an attempt to conserve heat. It’s — those two things obviously put up blood pressure and it’s — we called it cold shock back in the 1980s not because of the medical definition of shock, but simply because it is a shocking experience. And that the — in the UK, as an example, roughly 60% of those that die on an annual basis, die from this response, the gasp response of 2 to 3 litres is larger than the average volume required to cross the lethal dose for drowning, which, for a 75kg individual, is about 1.5 litres. So it’s possible with the first breath in to have crossed the lethal dose for drowning on immersion of cold, but I make the point that that’s somebody who’s taken from warm comfortable air and put into very cold water. The things that vary that cold shock response are things like fitness. It’s slightly smaller in fitter individuals. It still exists, however. The clothing worn, if the clothing can — the cold shock response shows both temporal and spacial summation, and what that means is the larger the surface area of the body exposed and the quicker the rate of fall of skin temperature, the larger the response, although, as I have mentioned, it peaks somewhere 10 and 15 degrees Celsius. So if you are wearing clothing that covers the body and slows the rate of skin temperature, then you will reduce the cold shock response. Habitation to cold; if you have been in cold repeatedly, cold water immersion repeatedly, as few as five two or three minute immersions can halve the cold shock response. And, finally, pre-cooling. I mean, obviously, the gradient between the skin temperature prior to immersion and its temperature on immersion is the driving force, but if you are already cold, if you have been pre-immersed because, for example, a boat is sinking and you are slowly being cooled prior to going into the water, then I wouldn’t expect to see a very large cold shock response. You will see the largest cold shock response, as I say, going from dry air into cold water.
Q. Thank you. You go on to say — we don’t need to turn it up now, but it is at paragraph 4.11 of your report. You go on to observe that there was an apparent slow rate of immersion in this present case and so from that, you draw the observation that the initial immersion is not or would not have been as significant a hazard as it might have been, for example, with a sudden capsize.
A. Correct.
Q. Thank you. This is a response, this initial response, which peaks, you tell us, in minute one of the immersion and attenuates in the first two or three minutes of immersion; that’s right?
A. That’s correct.
Q. Thank you. So from there, the next phase is what you describe as short-term immersion; yes?
A. Yes.
Q. Up to 30 minutes or so.
A. Yes.
Q. If we can move on to page 10 of the report {INQ010283/10} and it is paragraph 3.3 that you pick up short-term immersion. What is it that you mean by that and what are the associated risks?
A. So the next tissues to cool after the skin, which has provoked the cold shock response, will be the superficial nerves and muscles of the body and particularly in the limbs, because limbs are separate to cooling because they are cylinders, thin cylinders, with a high surface area to mass ratio and they have nerves and muscles running fairly close to the surface of the body. Roughly half the tissues of the body are within about 2.54 centimetres of the surface. Once those tissues cool, then the neural function and the muscle function is impaired and we know that when muscles get down to about 27 degrees Celsius, you suffer from physical incapacitation. Nerves will fire less effectively as they cool and as a consequence of which — I mean, the practical consequence that people will have experienced is you lose things like manual dexterity. You lose grip strength. You are unable to hold on to things. So your functional capacity is impaired. That becomes critical if that functional capacity is important to do things like hold on to flotation, to board things, to open things, to tie things together. This is just an impairment particularly of manual dexterity. It also impairs swimming ability. People lose the ability to co-ordinate swimming. They classically move from a long, slow stroke in a horizontal position to a much more upright position where they are now treading water, desperately trying to keep the airway clear of the water. So all of that is not a hypothermic response. At this stage, the individual is not hypothermic. It is pretty much a physical impossibility for an adult human to become hypothermic in less than 30 minutes in the most severe conditions. So quite a lot of what you see before that in terms of that physical incapacitation is this cooling of the neuromuscular function of particularly the extremities.
Q. Thank you, with its impact on the performance of essential survival functions?
A. Correct.
Q. Thank you. The third phase you identify for us is what you term long-term immersion, a period, any period, over 30 minutes; is that right?
A. Yes.
Q. Thank you. It’s now that the first risks of hypothermia arise; is that right?
A. That’s correct.
Q. Deep body temperature continuing to drop and the risk that the casualty becomes unconscious, you explain to us; is that right?
A. That’s correct.
Q. Thank you. And, again, the ongoing associated risk of drowning.
A. Yes. So as you call, hypothermia is defined as a deep body temperature below 35 degrees Celsius, where normal body temperature is 37. And I have shown in my report the stages of hypothermia and the associated clinical features, as well as the signs and symptoms.
Q. Yes.
A. Probably the most important is, as with many other extreme environments, the brain is amongst the first major organs to be affected. So people suffer from amnesia. They lose focus, lose concentration, and as deep body temperature drops towards 33 to 30 degrees Celsius, unconsciousness can intervene. Before that, there may well be semi-consciousness where people drift in and out of consciousness. When they become unconscious, if they don’t have a decent way of maintaining their airway clear of the water, they will drown. So if they are requiring to swim, to keep their airway clear of the water, obviously that stops with unconsciousness. If they are trying to hold on to something, so any purposeful physical activity to keep their airway clear of the water, then that will cease with unconsciousness. The important point about that is the unconsciousness occurs as a result of deep body cooling, but it occurs before you would die as a direct effect of deep body cooling. So it essentially shortens your survivability if you haven’t, at that point of unconsciousness, got some method of having your airway maintained clear of the water, such as an effective life jacket.
Q. Thank you. Can I ask you about a particular point that you make at page 11 and paragraph 3.4ii {INQ010283/11}. You tell us there — or you comment on the impact of swimming or attempting to swim in cold water. Is that an activity that in and of its own right accelerates deep body cooling?
A. Yes, it does. It is a common misconception because people know that if they exercise in air, they stay warmer. Well, water is quite a different fluid. Thermal conductivity and volumetric specific heat are much greater. So what happens when you exercise in water starts at around about 25 degrees Celsius, but it is very apparent below 15. If you exercise, you now — although you generate more heat, you also increase the movement of the water around yourself, so you increase convective heat loss. And I have already mentioned that when you stay still in cold water, the body will withdraw blood from the extremities, decreases skin blood flow, decreases muscle blood flow, and about 70% of your total body insulation then comes from unperfused muscle and about 30% from fat. Now, the unperfused muscle is variable insulation. The subcutaneous fat is constant because it’s always there.
Q. Yes.
A. But the problem with exercising in water is you will now send blood into the muscles to support the muscle function, and that destroys that insulation. So you now have people who are swimming. Although they have increased their heat production, they have more than increased their heat loss by destroying the muscle insulation and by stirring the water around the body. So we know from studies, lots of studies that we have done, originally Bill Keating did in the 1960s, that you’re better off staying still in cold water than you are trying to exercise to stay warm.
Q. Thank you. And you introduced your comments by saying that that is counter —
A. Intuitive.
Q. — intuitive for many people. All right. I want to ask you some questions about prediction of survival time in cold water now and we are talking in this terrain, I think, about long-term immersion, that period over 30 minutes. This is — is this right — and you pick this up at paragraph 3.4iii of your report, an exercise which informs decision-making in search and rescue operations?
A. That’s correct.
Q. And, in particular, setting and establishing and determining the duration of search and rescue operations; is that right?
A. Correct.
Q. How to decide, effectively, how long to maintain the search and rescue function?
A. Yes.
Q. There have been a number of models developed to estimate/predict survival times in cold water; yes?
A. Yes, that’s correct.
Q. You tell us through the report — and we will come back to those models. You tell us through the report that this is an inexact science; yes?
A. Yes, correct.
Q. Again, we will come back to that. Is it right that it’s because of that inexactitude and variability that authorities responsible for search and rescue typically extend search times beyond that period for which you can reasonably expect and forecast survival?
A. Yes, I mean, historically, the search and rescue times were based on the survivability predictions that come from various sources. One, for example, was Molnar’s work following the Second World War where the estimated survive time, 50% survival time, for water at 5 degrees Celsius was about an hour, 10 degrees Celsius about two hours, 15 degrees Celsius about six hours. And what search and rescue organisations have tended to do is to multiply that time by anything between two and six to have some kind of margin for search. So that’s the kind of — that was the kind of yardstick that people went by in terms of how long you should survive. We did the work which underpins the IAMSAR curve, which is in my report at figure 2, which was based on a combination of the UK National Immersion Incident Survey, a database of immersion incidents, and the US equivalent. We worked with the US coastguard in producing this curve, and it ends up being based on 12 survivors who represent the extremes of survivability in water between 2 and 27 degrees Celsius.
Q. Yes.
A. So — and interestingly, when you look at the curve, it’s not that far off of the old yardstick of multiplying the 50% survival time by a function of between two and six.
Q. I see.
A. So people were about right.
Q. So just to finish that point, I think at page 12 {INQ010283/12} of your report, paragraph 3.4vii is this where you tell us that historically, the yardstick was, for search and rescue operations, three to six times the predicted median survival time, that being the time for which 50% of people were expected to survive.
A. Correct.
Q. Not the case now because the maths is calculated a little differently; is that right?
A. The — yes. Well, maths is done slightly differently because the maths is now based on models of the human thermal regulatory system.
Q. I see.
A. Having said that, the numbers are reasonably good, which is encouraging, and they seem to support each other. But that — that survival curve in the IAMSAR curve is — really should be regarded as, you know, the extreme survivability capability.
Q. Yes, thank you. We will come back to the particular models shortly, but just so I am clear, that description you give of the calculation of three to six times the predicted median survival time being about the length of time you expect a search and rescue operation to continue, is that historic or does that remain a reasonable yardstick?
A. It’s historic, but as I say, when we have used actual data —
Q. Yes.
A. — of people’s survival and looked at the extremes of those — survival, then you come up with the curve, the IAMSAR curve —
Q. Thank you.
A. — and it’s not a million miles away from, you know, two hours times six is 12, so at 10, you would be saying 15.
Q. Thank you.
A. Two times six is 12, so …
MS LE FEVRE: Sir, it is 1 o’clock, just after. I probably have about another 25 minutes or so, I think, with this witness, so …
SIR ROSS CRANSTON: Well, do you mind continuing?
A. I am very happy to continue, sir.
SIR ROSS CRANSTON: Any problem? No, okay. Thanks very much.
MS LE FEVRE: Thank you very much. All right. Inexact science. You pick this up at paragraph 3.4i. Why is the exercise of predicting survival times an inexact science?
A. Because there is a whole host — I think I have mentioned some of them. There is a whole host of variables to do with the environment and to do with physiology that mean that it’s not possible to predict exactly. So some of those variables would be: is somebody wearing a functional life jacket? If you weren’t, then you are probably going to drown when you become unconscious. If you are, then you go on further and you are unconscious but alive, until the point where you would die as a result of the direct effects of hypothermia. Knowing what clothing people are wearing, knowing exactly what kind of water conditions they are in; knowing whether they’re hypoglycemic, not hypoglycemic; whether they have incurred any injury; whether they have got any habituation, you know, all of this — I mean, most of the information that search and rescue organisations will get is that there are people in the water and the water temperature is this, and that’s one of the reasons why the IAMSAR curve is just based on water temperature.
Q. Thank you.
A. But we think we can go — do better than that as we get more information about a particular incident.
Q. All right. Well, let’s move on to those models and the first is the model you have referred to a number of times, the IAMSAR curve. You have referred to your figure 2. We can look at that. It is at page 13 of your report at paragraph 3.4viii {INQ010283/13}. What this curve provides or sets out — is this right — is the realistic upper limit of survival time for people in the water who are wearing normal clothing from the time of entry into the water?
A. Yes, that needs to be qualified because, as I said, it’s the — it’s really based on 12 of the longest survival times across the 2 to 27.8 degrees Celsius range. The curve wasn’t based on people wearing just normal clothing. Indeed, that’s a mistake in the report. It’s based on people wearing different clothing. There is also — when the US coastguard made this calculation based on some of our data, they added a safety margin of — a prediction interval safety margin. So this is, I would argue, the very upper limit of survivability, and the reason it went ahead was because, you know, it errs on the side of caution. The chances of leaving somebody alive in the water following this curve is very slim. There is — only one person exceeded this curve and that was somebody wearing specialist protective clothing, an experienced diver. You know, it’s — although it’s there as a line, it’s not one that you would expect many people to or pretty much anybody to get to, but it’s a safety margin. And at the time of producing it, it was reasonable, but as you get more information than water temperature in, you — we think you can do better than that curve.
Q. Thank you. This is — the curve that you help us with is the curve that is relied on in the MAIB investigation report; is that right?
A. Yes, that’s right.
Q. It plots, as you have said, water temperature against survival time and so for a water temperature such as extant on 23 to 24 November 2021, 13 degrees, gives an upper estimate survival time of about 20 hours.
A. (Nods).
Q. You have sounded various notes of cautions about 20 hours. Do you think that this curve then is in fact a realistic upper survival time for casualties in this present incident?
A. No.
Q. And is that for all the reasons and the notes of cautions you have already set out for us?
A. Absolutely.
Q. The second model you refer to us through your report is — I think I have this name right — the Cold Exposure Survival Model?
A. Correct.
Q. CESM. And we can see you help us with this at pages 17-18 of your report at paragraph 4.4, {010283/18}. What is this model? What does this do for us?
A. So this is a biophysical model of the — of a human. It’s only a model of a — it’s only a model of the torso of a human and the reason for that is, as I have already mentioned, that actually there is very little heat exchanged between the environment and the body when you are in cold water because the limbs have essentially been shut down. So this model is a cylinder, which then includes a ring of fat tissue, muscle tissue and then clothing and environment. That’s by way of describing the biophysical aspects to it. That model can then mathematically be used to calculate heat exchange with the environment and that, that model does that. It’s then validated against laboratory studies and real life incidents as a consequence of which it’s used by roughly 12 — I think it’s probably more than that — search and rescue organisations around the world, it was developed in Canada by Dr Peter Tikuisis and it’s used by the Canadians.
Q. Thank you.
A. And it’s the basis of establishing an estimated survival time in — specifically for cold water immersion.
Q. Thank you. So we can see as we look at the table what it does, is this right, is that for given populations divided by gender and for given circumstances, environment and personal, so the sea state and the state of fatigue, the percentage of any given population that is likely to survive for a particular period of time, is that right?
A. That’s correct, yes.
Q. Thank you. So from this we could take a set of predicated median survival times, that being the 50% column, and that would be the median survival time for any one of those given populations, yes?
A. Correct.
Q. Now, we can see in this table that lines have been highlighted. But if we take an unhighlighted line, the top line, a male in a light sea state, not fatigued, the median survival period estimated at 10.9 hours, but the range running all the way from 6.1 to 19.4, is that right?
A. That’s correct.
Q. And is that figure of 19.4 as the longest figure reflected in this table, is that in fact about the same as the upper point of the IAMSAR curve?
A. Yes.
Q. Thank you. Do you accept that you can’t know whether any particular occupant of the boat was or wasn’t fatigued, tired or in a state of exhaustion?
A. No, I can only base that on the statements that I have read and, and knowing what people had been through prior to boarding the boat.
Q. Thank you. Considering that there are a number of unknown variables, and that we know that two individuals survived for 10 hours at least thereabouts, do you think it’s possible that some occupants might have survived for up to 20 hours, that 19.4 figure?
A. I don’t think that. I think that actually it’s a fairly remarkable achievement to have survived the 10 hours. The other point to make about the table that we are talking about is the population that this was designed from and for is a high-income western population where people are, tend to be fatter in that respect. And so even those numbers, when you compare it to individuals, just taking the simple metric of body fat are less fat, are likely to be higher than you would expect, than you would expect with the, you know, thinner individuals.
Q. Thank you.
A. So I think that that’s a rather optimistic — as I mentioned actually in the report that you would, for all of the reasons I mention in the report, not least of which the population on which those data are based, I think you would be looking much more likely at the 95-75% survival times as a realistic estimation.
Q. Thank you. If I were to push you a little on that. That’s the realistic estimation. What do you think the possible upper survival limit was?
A. It’s — it’s difficult to say because you are talking about — the nature of the information you have got is just as a group. You could look at individuals and that’s another way you can use this model, but we didn’t have anything like enough information to go down to the individual level.
Q. I see.
A. So you have to look at it as a cohort. You are looking at statistically or as a probability. I — I suspect having read the statements that the 10-hour survival was right on the limit.
Q. Thank you. I am going to ask you this, you have told us about the apparent slow rate of immersion and its relevance to immediate or cold shock. In your opinion, what bearing, if any, would a slow immersion have had on an upper survival time in relation to this incident?
A. I don’t think it has any direct implication. What it does mean is that fewer people than one would normally expect will die from the initial immersion.
Q. I see.
A. Although there are comments in various statements about people struggling very quickly on immersion and that — but that may well be due to an inability to swim and a poor life jacket. So there is — it’s not just cold shock; it’s actually just an inability to swim. There are also statements about people being washed away from the — from the boat that they were holding on to. Well, that’s the short-term immersion problem. They may be able to find their way back to the boat but that will happen repeatedly. So that really the major impact of not having as many immediate cold-shock related drownings is more people move on to the next stages of short-term and longer-term immersion.
Q. I see. Thank you. There is a third model you refer to in your report, it is the PSDA, the Probability of Survival Division … Aid?
A. Decision Aid.
Q. Decision Aid, thank you. And that’s a model, is this right, that predicts the cold functional time. What does that mean?
A. That’s — that’s pretty much the same as we have been talking about in terms of your ability to do things. Sometimes that’s predicted by an impact on peripheral temperatures. Sometimes it’s predicted by an impact on levels of consciousness and cognitive capability to help yourself. But it’s inevitably short. The problem with the models and the way we have to use them, had to use them is because of the lack of information needed to feed into doing a more individual, individual assessment is the functional time in the Cold Exposure Survival Model can only be based on the 50%, the 50th percentile, and one of the reasons why some of the survival times I am suggesting are less than the functional times is because the functional time is only based on the 50%.
Q. I see.
A. But generally if you want to work out what the functional time is, it’s around about 50 to 75% of the survival time —
Q. Thank you.
A. — whichever one you pick. And we also know, because we and others have done studies, that the time taken for the peripheral neuromuscular temperatures to fall to the levels where you get incapacitation in water at, say 13 degrees Celsius could be as less as, as short as 20 minutes.
Q. I want to just look briefly at this model as well. It’s page 18 of your report {INQ010283/18} and at paragraph 4.6, you explain to us it is a different mechanism a different prediction tool. Can I ask you this question. In this model, the figures for women, for their predicted median survival time, seem to be significantly higher than those for men, is that right?
A. Yes. So females have about a 10% higher, on average, body fat content and they also have a — their surface area to mass ratio is relatively bigger but their body fat advantage is the major difference.
Q. Thank you. So is that the explanation for that inconsistency as between these two models —
A. Yes. The Cold Exposure Survival Model does have an ability to put in a body fat content but of course we didn’t have that. The PSDA, which is a slightly different model, based on six cylinders rather than one, but we won’t need to go into that, assumes a body fat content but that again is based on a western, a western population.
Q. I see.
A. Which means that even if you put in lean — and I think I mentioned this in the report as well — even if you put lean into that model it’s still pretty fat.
Q. All right, thank you. Let’s take both those models off the screen. And you have referred to this a number of times now, the major limitation in applying any of these models to any particular set of circumstances is information or lack of information, is that right?
A. The more information you can get the more precise obviously your, your prediction will be.
Q. And with limited information, that limits your ability to be precise or specific about timings or individuals, is that right?
A. Yes. I mean, the models — having said that, the models were in general agreement in that the model, the modelling — I mean, remember, I was undertaking this in the context of a 20-hour proposal for survival and we — and the models came up with for males between 2.9 and 5.3 hours and for females between 3.1 and 6.6 for the reasons we have discussed, slightly longer. The time that individuals were in the water before dawn, when variously the reports say there were eight, 10 and 15 people still alive was between three hours and 53 minutes and four hours and 14 minutes. So — and then it was — it has been mentioned several times that at that time either between a half and two-thirds of the individuals in this incident were dead. So to some extent there is a reverse validation of the model in that the model would predict — those models would predict exactly that; that some people will have died before dawn because of those timings.
Q. Thank you. All right. In relation to those individuals who remain missing, you were asked by the Inquiry to consider whether it was possible or probable that any of those survived this incident. Your views are, what?
A. My views are that they would have been at the shorter end of the predicted survival times. The reason for that is that I have — that if you, if you look at their data all of them were reported to be slim build, thin and quite tall, ie not the short stocky individuals that you would expect to be able to do well. The other common factor of the ones that I could find information on, which was three of them, was they were all regarded as good swimmers and one of them had indeed said that he thought that he could swim it if — if it came to that. So I suspect that these three individuals were attempting to swim. One of them had been told by his parents to swim away from the boat anyway. So if you add those two things together, the likelihood that these individuals were swimming and that they were young and thin and tall, with one of them actually being reported to be average build, I — I suspect that that puts them into the area of a relatively short survival time.
Q. Thank you. You have told us already or given us the figures for your upper and lower estimates according to the modelling of how long individuals probably survived. Are you able to give us an idea of how long possibly, the top estimate of the possible survival?
A. Of these particular individuals?
Q. Yes.
A. Of the ones swimming?
Q. Yes.
A. Well, I would have — I would have thought they would do well to get, because of their, as I say the fact they are swimming and their — their body fat content they would do well to achieve anything approaching 50% population. But I mean that’s, that is really stepping a fairly long way along the speculative branch.
Q. Thank you. Well, I won’t push that question any further. You tell us at paragraph 4.10 of the report, at {INQ010283/20}, that you believe that the majority of the boat occupants were alive at 03:24 hours, is that right?
A. That’s — yes.
Q. That you think that some may have died by 07:03 hours?
A. Which is essentially what we have just been discussing in terms of predictions and times.
Q. Thank you. And thereafter, it’s those figures that you take from the models as your best estimates?
A. Yes. And those, some of those figures from the models, best estimates actually cover the time to sunrise.
Q. Thank you. You were asked by the Inquiry to comment, so far as you were able to, on the mechanism and cause of the deaths of those who are known to have died. You respond to that request primarily at paragraph 4.3 of your report at {INQ010283/17}. You tell us that some, but not the majority, may have succumbed to cold shock on immersion and drowned. Others may have drowned due to a lack of swimming ability and the absence of a source of buoyancy and most will have died when due to peripheral local cooling they could no longer hold on to a boat or exercise to keep their airways above water, having no functioning life jacket, or may have lost consciousness due to hypothermia?
A. Correct.
Q. And others may have cooled to the point of cardiac arrest again due to hypothermia?
A. Correct.
Q. Is that the best evidence you can give in respect of the mechanism cause of death?
A. Yes.
Q. Thank you. I want to ask you now finally a little about recommendations and improvements. You know that this Inquiry is charged with identifying recommendations liable to minimise the repeat of such accident. At paragraphs 4.12 and 4.13 at {INQ010283/21} of your report, you talk about the provision of information or advice which you consider might have been helpful to those on board the boat, yes?
A. Correct.
Q. You note that this is a list of information that wasn’t passed to callers in the calls to which you had access?
A. Correct.
Q. How easy do you think it would have been to pass information, this detail, to callers from this boat?
A. Almost impossible.
Q. Is it possible —
A. Verbally I mean.
Q. Verbally, yes. You do raise the possibility at paragraph 4.13 of providing this information by text, text message and translated as appropriate. Is that something useful at least for the future, do you think?
A. I think — I think so. I mean, just people being aware of some of the things I list, and I am not going to go through them, but I mean for example staying still, not swimming, putting on as much clothing as possible, making sure that, you know, you’ve — things like ditching the engine, which is essentially pulling the boat under and is serving no purpose. Some of these things may help, I mean … Yes, it’s, I mean, but it’s just a remarkably difficult situation. These might make small, small differences and be of benefit and I hope that they would.
Q. Thank you.
A. Yes.
Q. This, I suspect, is taking you squarely back into the realms of speculation, but I will ask the question. Had those on board this particular boat received this advice, is it possible to say how it might have altered their behaviour?
A. Well, I think that those that — again, as you say, it is speculation, but those who I believe set off to swim away may well have stayed with the boat. That doesn’t guarantee survival, but I think it may well have lengthened survival time and given them more opportunity to be rescued.
Q. Thank you. You next deal at paragraphs 4.14-4.18 with a mass casualty triage tool {INQ010283/23}. Can we turn that up. It is figure 3 at page 23 of the report, please. Thank you. What issue is this tool intended to address?
A. Well, normally, when groups go to rescue people in the water, you are dealing with small numbers, one, two, three, maybe four people and it’s possible in that situation to remove the individuals from the water and then do a triage and to ie work out what the best thing to do for each of those individuals is. There isn’t a published In-Water Mass Casualty Triage Tool and that’s partly because this is a relatively new issue. So we thought it would be of value to have a tool that would allow you to identify people in the water who were most at risk and most in need of assistance because clearly if you have got 30 people in the water, you cannot remove them all from the water and then make a decision about who needs the help. So this is just to help make sure that you prioritise those that need assistance. And, as I say, to my knowledge this is the first tool that allows you to do that.
Q. Thank you. So, I think it provides a sort of flowchart effectively for those involved in making decisions about where best to allocate resources, is that right?
A. Exactly.
Q. Thank you. You were closely involved in its development, is that right?
A. I was.
Q. Thank you. Are you aware that the RNLI has developed a tool that looks remarkably like this triage tool?
A. I am and I know why.
Q. Why’s that?
A. Because when we first did this — and I’m talking about Dr Paddy Morgan, myself and others — we presented it at a conference in Rotterdam. Dr Morgan presented it and there were obviously people in the room and obviously one of the reasons we presented it was to make it publicly available as soon as possible because we believed it would help save lives. What then happened is Dr Morgan was invited to a meeting with the RNLI when he discussed this triage tool and as a consequence of which they have adopted the same triage tool.
Q. Thank you.
A. It’s an earlier — I have it say it is an earlier version than the one at figure 3 because as part of our publication process —
Q. Yes.
A. — we revised this slightly.
Q. You revised it and you included the reference to “Airway observed to submerge”, is that right?
A. Correct. Because if you are actually there and you see somebody’s airway being clear of the water, but then go under it they are a high priority for rescue. And the only thing I would recommend really is two things really from this: is that firstly that we try and align any versions of this that are out there because there’s nothing worse than having slightly different iterations of it.
Q. Yes.
A. And, secondly, it — it probably needs to be tested. In — it’s all theoretical at this time. I mean, I think it’s logically theoretical but it would do well to be tested.
Q. Thank you. Next, and finally, you make reference at paragraph 4.18 of your report, {INQ010283/24} to ongoing work that you and others under your direction I think are doing with the IAMSAR curve that you have told us about. Is that ongoing?
A. Yes. There’s two things that are ongoing. Firstly, we have been, as I have mentioned, involved in the Probability of Survival Decision age — helping the — age — “Aid” rather, helping the US Coastguard develop that and at the moment that’s being considered by His Majesty’s Coastguard as a step forward in terms of refining the decisions as to when to stop a search.
Q. Thank you.
A. But we are also always attempting to collect more data in order to inform things like the IAMSAR curve. And one of the problems we have with that is that — the National Water Safety Forum do operate the water incident database, the wave database, but it’s, you know, it’s done with difficulty. It could do with being — and we could do with having a proper — turning that into a proper national database and making sure that those data are collected because pretty much everything I have said to you today is founded on that kind of data and, and that information. And so, I mean I think part of that would be having drowning prevention and water safety as a portfolio of a senior minister, so that there is some real drive to make sure we continue to collect these data so this doesn’t happen again and, if it does happen again, we have continued to get better and better information to refine the kind of conversations we have had.
MS LE FEVRE: Thank you. Thank you, Professor Tipton. Chair, I have no further questions for Professor Tipton. Questions by SIR ROSS CRANSTON
SIR ROSS CRANSTON: I think we might ask you to develop that a bit more in writing if you don’t mind. Could I just ask you about the triage. You published that in November last year, it was peer reviewed. Have you had any commentary — you say it’s theoretical of course at this stage, but have you had — sometimes when you publish a paper you get some reaction.
A. Yes, you do, I can confirm that. We have no — had no reaction. It’s generally been welcomed but because it’s the first of its kind, it’s — I mean, I think people are still you know giving it some consideration. It was also published along with the Ministry of Defence, who had a representative in that Rotterdam meeting, and hence the particular tool that you see is also looking at things like a stranded submarine with military personnel, lots of military personnel at the surface. Hence the first part of it is all to do with whether you are under fire or not. So, no, I think it’s being considered. I am unaware, although I am not 100% sure what everybody is doing in this area, whether or not this has been the subject of any training or any exercises, but I think it certainly should be. As I say, I think it works perfectly reasonably theoretically, but obviously that’s a step away from practically.
SIR ROSS CRANSTON: Yes. You mentioned the advice and you said frankly that it would be impossible to pass all of that. But wouldn’t it be the case that you could give just the key advice such as: float to live, don’t swim?
A. Yes, no, I think, I think so. I am just, you know, having listened to the conversations, which obviously are incredibly sad, you just get the impression that just the communication of information in that environment is tremendously difficult. But I would — I don’t doubt that telling people to, you know, stay as still as possible, wear as much — a lot of the trouble is some of the advice you would want to give people before they are in that situation. But certainly when they are in that situation staying still, entering the water slowly, you know, there’s some of that advice that one would hope would be of some benefit.
SIR ROSS CRANSTON: Yes. You said, and correct me if I am wrong, that you didn’t think that the IAMSAR model was up to scratch.
A. No, that model is fine, but I think what people need to appreciate is that it’s based on extreme survival. So it’s not something that one would necessarily expect and really when you consider an incident like this it’s how far removed from that people will be. Because that, that line which, as I say, comes from the 12 people who have survived the longest across that temperature range may have been wearing an immersion suit, may have been … You know, there is all kinds of things and it is perfectly reasonable as a guide to say: Go and look. But I mean, I have had contacts with search and rescue organisations who all know that if somebody is in a severe sea state and the water is 13 degrees, at 20 hours is a lot longer than somebody is going to survive. Now, the problem comes when you have committed a resource to that and they could be somewhere else helping people that they could, you know, so —
SIR ROSS CRANSTON: Yes.
A. — you’re tying up resource and that’s one of the — that was one of the motivations to go down the route of coming up with these other models that were going to be much more precise.
SIR ROSS CRANSTON: Yes. You said with the Cold Exposure Survival Model that had been adopted by I think you said 12 organisations around the world.
A. Yes.
SIR ROSS CRANSTON: But any in the UK, to your knowledge?
A. No, I think no. The UK is still using the IAMSAR, as are, you know, 193 other countries under the convention. The actual number is, yes, a dozen countries and including the Canadian search and rescue arm of the Royal Canadian Airforce are using the Cold Exposure Survival Model. The coastguard, the last time I checked, we had done some work to start their evaluation of the Probability of Survival Decision Aid, which is the US Coastguard model, for its use within the UK. I am unaware of where that’s got to.
SIR ROSS CRANSTON: Yes. I see there was a footnote to Dr Tikuisis’ exploration of the model.
A. Yes.
SIR ROSS CRANSTON: I am just wondering, I think that’s 2008. I can’t find it again. Was that peer reviewed, do you know, to your knowledge?
A. Yes. No, the — Dr Tikuisis has presented this model at international meetings, he’s presented it at and published it as what was DRDC, the defence —
SIR ROSS CRANSTON: So well accepted?
A. It is well accepted.
SIR ROSS CRANSTON: Yes. Just finally, we heard evidence in fact the first day from Issa Omar, who survived, one of the two survivors and he described amazingly — an amazing man — he survived, but he described the effect on his legs. Would that be what you set out there as the muscular rigidity? You obviously didn’t examine him and you can’t —
A. No.
SIR ROSS CRANSTON: Is it likely to be that?
A. Probably not.
SIR ROSS CRANSTON: Because I couldn’t understand what he was talking about, but it sort of fits with what you say here.
A. No, I don’t think that’s the same thing. The cooling I am talking about of the neuromuscular cooling of particularly the superficially running nerves and muscles in the arms is the thing that leads to physical incapacitation. That would have stopped Issa from being able to swim, which it clearly didn’t. I — whether it’s just due to protracted time in cold water, to salt water, whether there was clothing rubbing, I don’t know. I don’t know the reason for that.
SIR ROSS CRANSTON: No.
A. What I suspect also it’s worth just mentioning is that because I believe that Issa was right at the limit of where he could be and when he talks about swimming, resting, sleeping I suspect that the sleeping was probably, you know, drifting in and out of consciousness and the fact that he stayed afloat when he wasn’t doing anything suggests that he had a reasonable amount of buoyancy from whatever source.
SIR ROSS CRANSTON: Yes. Well, thank you very much and my counsel team will tell me it was an entirely inappropriate question. Well, look, thanks very much. Thanks for the report and thanks for coming along today and giving the evidence, it has been extremely helpful. So Professor Tipton, thank you.
A. Thank you, sir.
SIR ROSS CRANSTON: Right.
MS LE FEVRE: We have no more witnesses coming today so that will end proceedings so far as evidence is concerned.
SIR ROSS CRANSTON: Then I think we have the RNLI tomorrow.
MS LE FEVRE: We have got them tomorrow, yes, that is right.
SIR ROSS CRANSTON: Okay. Thanks very much, everyone. (1.40 pm) (The Inquiry adjourned until 10 o’clock, on Tuesday, 18 March 2025)
I N D E X
MR GEORGE PAPADOPOULOS ………………………….1 (affirmed)
Questions by MS MOFFATT …………………..1
Questions by SIR ROSS CRANSTON ……………94
PROFESSOR MICHAEL TIPTON ……………………….96 (called)
Questions by MS LE FEVRE …………………97
Questions by SIR ROSS CRANSTON …………..141