Tuesday, 18 March 2025 (10.00 am)
SIR ROSS CRANSTON: Good morning, everyone. Good morning Mr Ling.
THE WITNESS: Morning.
SIR ROSS CRANSTON: Could you please read the affirmation?
MR SIMON LING (affirmed)
SIR ROSS CRANSTON: Yes, thank you very much. Mr Rory Phillips KC has got some questions for you.
Questions by MR PHILLIPS
MR PHILLIPS: Mr Ling, good morning. You have provided a witness statement on behalf of the Royal National Lifeboat Institution, the RNLI, which is dated 14 November and is 33 pages long; is that right?
A. That’s correct, sir.
Q. Could we bring up the statement, please, which is at — there it is {INQ010101/1}. Thank you very much. You explain there in your second paragraph that you have been employed by the RNLI for nine years and you are currently the head of lifeboats. You say that you have been in that role for what must now be, I imagine, about three years; is that correct?
A. That’s correct.
Q. And that your reporting line is up to the lifesaving operations director. You talk about your previous service in the Royal Air Force, and then at the end of the paragraph, you explain, having given some of your maritime qualifications, that you yourself volunteer. Is that at a local lifeboat station?
A. That’s correct, sir, at Poole lifeboat station.
Q. How long have you been doing that?
A. Approximately five years now.
Q. Thanks. And has that involved search and rescue in the Channel?
A. No, it hasn’t.
Q. So far as your role in November 2021 is concerned, what were you doing then?
A. I was then employed as the maritime standards and performance manager.
Q. And what were the — what did that role involve?
A. Principally, it was to lead a small team of specialists that go and undertake assurance activities on the coast. What it essentially means is that they will go and spend 24/36 hours with a lifeboat station and just observe how they deliver lifesaving effect and issue behavioural change at point of delivery, which is very important, but also capture a whole raft of information, which gives us insight into leading indicator risks. So where is it that our crews are finding it difficult to comply with our procedures? Where do we need to make improvements around training equipment and so on?
Q. Thank you. Thank you very much. So far as your current role is concerned, you deal with that, do you see, at the bottom of the screen there in paragraph 3 and you set out your — the various aspects of that new role. Is that complete? Is there anything else we need to know about the role?
A. No, I think that covers the role quite accurately.
Q. Fantastic. Thank you very much. Can we go to the next page, please {INQ010101/2}. Here in paragraph 4, you talk about the Institution itself. What is its purpose, please?
A. Its purpose is to save lives at sea.
Q. And we can see that it was founded in 1824 and has saved during the over 200 years now some 143,000 lives. You give figures there for the lives saved and people aided by the organisation in 2023. So far as the structure, the internal structure, of the organisation is concerned, you help us there at paragraph 6, the chief executive and, above the executive level, a board of trustees; is that right?
A. That’s correct, sir.
Q. Thank you. And in the end, ultimate governance responsibility, I assume, rests with them.
A. That’s correct.
Q. Thank you. So far as the day-to-day work of the RNLI is concerned, you explain in your statement that, of course, like all charities, you are reliant on volunteers. Can you give us some idea of how that works in practice?
A. Yes. So the vast majority of our lifesaving effort is delivered by volunteers. We have around 5,500 operational volunteers and they are supported by a small army of around 30,000 other volunteers that immerse themselves in all sorts of essential activity, whether it be fundraising, manage our shops, shore crew support roles. We have around 1,600 staff in the RNLI. The majority of those are based in Poole at the headquarters, the sports centre, but we also have staff in the regions and in all-weather lifeboat stations as well.
Q. Thank you. If we could turn to paragraph 7 and bring up this page and the next page ideally. Can we do that? Pages 2 and 3. Thank you very much. You set out there the three strands of broad activity: (i) search and rescue lifeboat service; (ii) lifeguard service; and then (iii), as it were, your education and accident prevention programme. Today, for obvious reasons, we are going to focus more on the lifeboat service. Now, just checking, however, in relation to those three strands, are you describing there in your statement the situation as it was when you made it in November last year and is there any difference between the situation then and the situation in November ’21?
A. Yes, there is a slight change. So we have now assumed the international team as well within lifesaving operations, so we have gone from a three-legged stool to a four-legged stool. So we have got lifeboats, lifeguards, water safety and a small team that do some incredible work in the international space.
Q. So that would be under number (i), or are you saying it’s a fourth —
A. No, they all come under — we have done some restructuring recently linked to the new chief executive arriving.
Q. Yes.
A. So we now have a chief operating officer, which was formerly known as the operations director, and that role looks after the six regions and also the four elements of lifesaving that I have just outlined.
Q. Okay. Thank you very much. And in terms of the assets available, in (i) of paragraph 7, you described over 400 lifeboats at 238 lifeboat stations across the UK. Again, is that the situation as it pertained in November ’21 or is that situation more recently?
A. No, that’s the situation as it was —
Q. Thank you very much.
A. — in 2021.
Q. Now, looking at the lifeboats themselves in a little bit more detail, can we turn on, please, to paragraph 13 of the statement and, again, if we could have pages 4 and 5, that would be helpful {INQ010101/4}. Thank you. Here, you explain the two main classes of lifeboat, all-weather and in-shore, and that there are, as it were, subcategories within that, and you then set out in paragraph 14 where they were based {INQ010101/5}. And, again, just to confirm, this was the situation as in November ’21, was it?
A. Yes, with the exception of one. At Ramsgate at the time of 2021, we were operating a Trent 14-metre class lifeboat.
Q. As opposed to Tamar?
A. As opposed to Tamar —
Q. Yes.
A. — which was replaced last year.
Q. Thank you very much. And is it right that the three stations that serve the Dover Strait area, which is the area we are principally concerned with, are Ramsgate, Dover and Dungeness?
A. From an all-weather capability perspective, yes, sir.
Q. Yes, thank you. Now, turning on, please, to paragraph 15 of your statement, page 6 {INQ010101/6}, here you deal with the capabilities of the various craft. And, again, I’m sorry this is stuck record, but are you talking there about the situation as it was in November ’21 or are there any differences?
A. The numbers may have changed ever so slightly —
Q. Right.
A. — but those are the current numbers.
Q. Okay. Thank you very much. Well, here you show the capabilities, as I say, of the boats; crew size, first column; survivor capacity self-righting; and then survivor capacity non-self-righting. For the non-maritime people in the room, can you explain the difference?
A. I will seek to do that, sir. I think the easiest way to try and explain it is with the survivor capacity self-righting, our lifeboats are designed to self-right should they be knocked down, and there’s lots of very clever centre of gravity maths associated with that which I would not profess to know. But what we are indicating here is if — survivor capacity self-righting would suggest that wheelhouse is secure and shut and we have the survivors inside of the lifeboat. Therefore, that’s the maximum we would have in order to survive a knockdown and self-right. The column to the right of that is non-self-righting, which is how many people we could physically carry on the deck of the lifeboat or on the lifeboat, but we would not be able to self-right.
Q. Okay. So taking an example so everybody is clear and using Tamar, to keep everybody recover — undercover inside, your maximum capacity, 44.
A. (Nods).
Q. But if you have more than that, you have to hold them on deck —
A. Yes.
Q. — outside, and that could get you, in theory, up to 90.
A. That’s correct, sir.
Q. In practice, do you seek to confine the people taken on board to 44 in the case of a Tamar or is there a flexibility? How does it work?
A. Yes, there is a flexibility, so it all depends on the rescue demand that’s presenting. Obviously, if you are going out in a force 10/force 11 10-metre sea to pick up a fishing boat crew, we would want to put them in the wheelhouse. It would not be appropriate to have large numbers of casualties on a deck in extreme weather. So the coxswain will make a decision. His aim is to rescue people from the water and then his duty of responsibility is then to provide for the welfare of the casualties that he’s rescued.
Q. So it’s a decision for the man or woman in charge in the moment?
A. That’s — that’s correct, but in most cases, outwith mass persons in the water, which is a slightly different type of rescue demand —
Q. Yes.
A. — the casualties would be brought into the wheelhouse, where we can best look after them.
Q. Yes, and that effectively means that a self-imposed limit, in the case of Tamar, of 44.
A. Yes, but it’s — outside of the Channel, again, we would not be confronted with those numbers —
Q. No.
A. — but we could. It is inconceivable that in a cruise liner event or — or a tourist boat event might present that. But yes, the answer to your question is we could carry up to 44.
Q. And the sort of approach you have described, was it a general approach or did you have a specific approach or set of guidelines for dealing with search and rescue from the small boats?
A. What we had to quickly learn in relation to small boats is that is a number that’s based on a — some very clever engineering around centre of gravity and stabilisation. What our crews were faced with is the reality of actually — in the case of a Shannon, having 43 people on the deck in a 13-metre boat means you cannot move on that boat, and if some of the casualties that you have are very seriously ill and, for example, in need of oxygen therapy, you are very quickly running out of space. And the final point I think I would add at this time, of course, was Covid was still prevalent and so we do have — did have a duty. We would avoid bringing casualties into the wheelhouse, unless they were very sick or very weak, as a Covid prevention measure.
Q. Yes. So in practice and at the time with which we were concerned, dealing with small boat rescues, these numbers are very much at the high end of anything that was practically possible; is that fair?
A. That’s fair, sir, and an example of that would be the 7-class at Dover where we really systematically said as soon as we get to about 50 casualties, we should be calling for help because whilst the 7 is a 17-metre lifeboat, the biggest one in our fleet, our experience of dealing with very sick casualties again, who are immobile and might need the assistance of a helicopter paramedic, we need deck space to land a paramedic. So it is a balance that has to be considered by the coxswain all the time. Ultimately, it is about making sure that having rescued people, we can adequately care for them.
Q. Yes. Finally on this, I think, can you help from your own knowledge as to the sort of maximum capacities in terms of small boat rescues. Let’s say the 7, the biggest of your — the longest of your boats. What sort of figures were you taking on board at this period in November ’21, for example?
A. I think in about November ’21, the sort of numbers we were being presented with were in the 20s and 30s, but what we were finding on very busy days is the lifeboat would rescue a boat of 30 people and then instantly be re-tasked to another boat of, say, 30 people, and so suddenly we are getting into reasonably high numbers. And I can recall, as my evidence suggests, as the numbers of casualties crossing increased —
Q. Yes.
A. — again, that presents challenges to our coxswains in terms of physical rescue capability if they arrive on scene.
Q. So it sounds from your answer as though there were occasions where the first tasking was completed. The 30, let’s say, were taken on board and an immediate further tasking to another similar sized boat and you would suddenly find 60 on board.
A. That’s correct, or more.
Q. Or more.
A. Yes.
Q. Yes. But presumably there were other occasions — like all lawyers, I am now adding another question, having said it was the last, but there were other occasions where the coxswain took the view that that was it and he then had to go into a tug haven or wherever and unload before doing any further tasking.
A. Absolutely, and that would be on the back of a dynamic risk assessment around the weather conditions at the time, the conditions of the casualties —
Q. Yes.
A. — and the need to get them to a higher standard of care, which is our — basically, our basic procedure would be to care for the casualties, but seek to hand them over to a high standard of care as soon as possible.
Q. Yes. Presumably, in all of this — and we will come on to this in much greater detail in a moment, but in all of this, imagining a situation at this time, November ’21, all of those decisions in liaison with coastguard.
A. That’s correct.
Q. Thank you. Thank you very much. Can I turn now to the topic of training which, you deal with in your statement from this point on. Do you see 16, the heading above it is “Training”? And there you give details — we don’t need to go through it all — of the training provided to your crew members, which is extensive, sea safety, survival, a wide range of courses. You have your own college, don’t you?
A. That’s correct.
Q. Yes, or at the regional centres and, of course, training at the local stations as well. Presumably, as well as dealing with general seamanship, if I can put it that way, a large proportion of this training is specifically focused on search and rescue.
A. That’s correct. That’s more specifically aimed at the coxswain than the navigator, who will undertake our search and rescue planning course and it’s a prerequisite to be qualified as a navigator on an in-shore or all-weather lifeboat, but the crew will also be made very aware of search patterns. But essentially, search planning and execution is really the specialism of the coxswain and the navigator.
Q. The two senior people in any crew; yes?
A. The two or three senior people, yes.
Q. Thank you. Then so far as the typical volunteers are concerned — and I am not saying that with any disrespect, but, as it were, people other than the senior members, you tell us in paragraph 19 — and if we could have pages 7 and 8 {INQ010101/7}, please — something about their training, which you describe as their full training pathway. Do you see? Two years, although those with a maritime background may complete more quickly. And you make the point later in this paragraph that, of course, thereafter, there is continuous updating.
A. Yes, it’s possible that a crew member could join the RNLI and only attend one course at the college, which is the mandatory crew emergency procedures course. It’s rare, and because the college does offer state of the art facilities and world-class training, a lot of crew will always want to come to the college. So it’s often a balance of picking the right course for the crew to accelerate them and, as I have signposted there, that could be dependent if they join us with maritime experience already.
Q. Yes, but once they have got their badge, as it were —
A. Yes.
Q. — they have to keep topping up as their work as volunteers continues.
A. That’s correct, and we have recently changed how that works, so we have introduced a new competency framework and a new currency framework. At the time of November ’21, we were operating to a system where we tracked and trained to competency, but didn’t necessarily manage currency.
Q. Can you explain the difference briefly to us?
A. Yes. So what we have moved from is instead of — in the old system, a crew member would achieve a number of badges on their arms, to use the Scout analogy. Once they had completed all their badges, they are considered an RNLI fully trained crew member. But what we recognised is that, actually, currency was a form of competency in its own right and so we devised a range of exercises that would be undertaken that would ensure, over an 18-month period, that every crew member did every type of SAR drill on a lifeboat and therefore maintained currency, and we now track that.
Q. Thank you very much. The next topic I want to turn to, please, is your relationship with His Majesty’s Coastguard, and this begins in paragraph 22. We can just see it at the bottom right hand screen, so could we have the next two pages please, 8 and 9 {INQ010101/8}. Thank you. You explain here first in paragraph 22 — do you see the fourth line — that your lifeboats are declared assets to the coastguard. Again, can you help us, please: what is a declared asset?
A. A declared asset is a capability that has been — that meets a certain set of standards which are set by the MCA and, therefore, can be declared to His Majesty’s Coastguard or other tasking authorities in other parts of UK and Ireland as a capable lifesaving asset —
Q. Thank you.
A. — available for tasking.
Q. Thank you. In broad terms, again, what is the nature of the relationship between the two institutions and how do they work together in practice?
A. In the case of His Majesty’s Coastguard, ever since I have joined the RNLI, we have continued — and I see no reason why we shouldn’t have — a really close relationship, which is to be expected because we are principal SAR partners. We are tasked on average 8,500 times a year by the coastguard and I would say we have a very strong and close relationship with them.
Q. So in short, the coastguard co-ordinates and gives you the tasking and you then accept or not — and we will come to that — whether to launch.
A. In — in nearly all cases, that’s correct, sir. We do have the ability and right to self-launch. That occurs, I would say, less than 5% of the time —
Q. Yes.
A. — and that would probably be a lifeboat crew sat in a station and they see somebody or a member of the public start screaming because somebody has fallen into the lock or the quay or whatever. So we would initiate a launch, but we would then contact the coastguard immediately to say we have self-launched and why, and therefore, the coastguard would then take over command and control of that incident.
Q. Yes. Thank you very much. But as you say, that’s — it is statistically a very rare occasion —
A. It is.
Q. — the self-launching.
A. It is.
Q. Thank you. And I think it’s important to make the point, which you do in paragraph 5 of your statement on page 2, if we could just quickly flick back to that {INQ010101/2}, that, of course, you are separate from coastguard and indeed independent from Government and not governed by Government.
A. That’s correct.
Q. Thank you. Now, so far as the detail of the operations between you and the coastguard are concerned, can we please look at {INQ000655/1}. That, as it says, is an agreement between you and the MCA on search and rescue operations and planning. The date of the document, which unfortunately you can’t see on the screen anyway, is November 2010. As far as you know, was this agreement in force at the time of the incident in November 2021?
A. Yes, it was, sir.
Q. Thank you. And turning, please, to page 3 {INQ000655/3}, there we see the date actually as we flick through at the top of the screen. Page 3 is the contents page and so we can see in broad terms what is covered by it; objectives, reference, scope, search and rescue, the role of the IMO, etc. And the objectives, if we could turn to page 5 {INQ000655/5}, please, were: “To confirm [search and rescue] terminology “To promote good communication between MRCCs [coastguard] and Lifeboats “To confirm understanding of Search models and Patterns “Adopt use for training and operational requirements …” Etc. So then going back, please, to page 3 {INQ000655/3}, as I said, we can see it also addressed the role of the IMO, of the coastguard, of the RNLI, and also dealt with the search and rescue mission controller, the SMC and the SMU — sorry, SRU, and the on-scene co-ordinator. We will come back to all of those at various points later. But it looks as though it also dealt with some more detailed operational areas; search area determination, rapid response, etc, etc, etc. Turning, please, to page 4 {INQ000655/4}, we can see there were a variety of appendices, which included pro forma tasking form, situation reports and other documents. If we could remove that document, please, and now go to the memorandum of understanding between the two organisations. That is {INQ000096/1}, I hope. Yes. Now, this document, if we go to page 8 of it {INQ000096/8}, please, lists additional agreements between the parties, so between MCA and RNLI, and at the bottom, do you see there the last box suggests — right-hand box under “Review” suggests that the agreement we have just been looking at, the 2010 agreement, is or was then under review. Is that still the situation, as far as you are aware?
A. Yes, it remains under review.
Q. Can you explain why?
A. I think the — we recognise that the memorandum of understanding, which is a wider document covering the sort of strategic relationship between the RNLI and HMCG, is in need of review. It was delayed through Covid.
Q. Yes.
A. We have an agreement established between both organisations that that document will be redrafted and issued in May of this year, and it was felt that rather than review the memorandum of understanding and then go into another document which is slightly more bespoke around search and rescue planning might not be the right course of action. So we would wait for the higher document to be agreed and then both teams will work on what is essentially our bible around search planning.
Q. Yes. So just to unpack that a bit, so the 2010 agreement is still under review, but also still in force.
A. That’s correct.
Q. And so is this document we are looking at — we can go back, please, to page 1 of it {INQ000096/1} — which is the memorandum of understanding.
A. That’s correct.
Q. Now, are you able to help us with this question: why was it thought necessary, from the RNLI’s side anyway, to produce a memorandum of understanding in 2020 when you already had the main agreement, if I can put it that way?
A. The main agreement might be slightly misleading because that agreement is basically an agreed framework for how we manage one particular aspect of search and rescue, ie the search and the planning around a search, so common lexicon, common language, common process, such that we are completely aligned in terms of how we are tasked and how we execute a search. Whereas I think moving into 2020s — and I use the word “I think” — the memorandum of understanding was just another way of confirming our relationship and — and intent with our principal SAR partner.
Q. And, again, just so we are clear, this memorandum is also in force and effect today; is that right?
A. That’s correct, accepting it is in need of review and I would expect some of the detail to change.
Q. And will that also happen by May this year, as with the main agreement?
A. Yes, so the hierarchy of need in this stage is to first of all get the memorandum of understanding redrafted and signed off by the director of coastguard and probably the chief operating officer, and then having done that and noting any changes that may come from that process, our teams stand ready to then see if there is any requirement to change the SAR planning understanding document.
Q. Thank you. So now some questions, if I may, about Border Force, and we will obviously talk in more detail later about the small boat crossings again. But it’s right, isn’t it, that in about 2018, Border Force became involved in responding to small boat search and rescue incidents in the Channel?
A. I wouldn’t know when they started responding, sir, but that — that’s certainty when we started to see more small boats crossing.
Q. Thank you very much. And, again, we will come to that. You deal with that in your statement, the increase in crossings that you observed. But in November ’21, you, the RNLI, were working alongside Border Force in responding to small boat crossings.
A. That’s correct.
Q. Now, in relation to Border Force, there is no agreement or memorandum of understanding, is there?
A. No, sir, not between the RNLI and UK Border Force.
Q. Thank you. And the two documents we have looked at, your agreement with the MCA or coastguard and the memorandum of understanding, they do not address, do they, the role of Border Force?
A. They do not, sir.
Q. Thank you. Can we look, please, at {INQ006084/1}. Now, that is an internal policy document, guidance document, from the RNLI, heading “Working with External Agencies”, objective: “To provide guidance on Working with External Agencies.” That document, as far as we can see, doesn’t address Border Force.
A. That’s correct, sir.
Q. Was this document, as far as you are aware, in force, in place at the time of the incident in November 2021?
A. I couldn’t categorically give you an answer on that, sir.
Q. Thank you. So far as France is concerned, did you, at the time of the incident, have any form of working relationship with France or French agencies in relation to search and rescue in the Channel?
A. Not that I am aware of, sir.
Q. Thank you. And would there ever be, as far as you are aware, a direct contact between the RNLI or RNLI lifeboats or crew with the French coastguard or French authorities?
A. Not that I am aware of, sir.
Q. Thank you. Now, could we go back to your statement, please, and pages 8 and 9, paragraph 22 {INQ010101/8}, and some questions, please, about tasking and co-ordination in relation to search and rescue. We have touched on this already, but you explain there how the coastguard is responsible for co-ordinating rescues at sea, including determining the deployment of appropriate assets; is that correct?
A. That’s correct.
Q. Thank you. Now, in the later paragraphs, 23 and 24, you set out, as it were, the normal procedure. In other words, 23 {INQ010101/9}, the coastguard requests a lifeboat by paging the relevant station duty launch authority, which is a particular kind of volunteer and leader within the station, and that person then has to decide whether to agree the tasking request and, if so, the process of launching, mustering the crew, etc, takes place. Is that a fair, if crude, summary of what happens?
A. Yes, sir, that’s exactly what happens.
Q. Thank you very much. Now, moving down the page, which is page 9 of your statement, to paragraph 25, you say that if the DLA, the launch authority, authorises the tasking, they will page the crew and brief the coxswain before the launch and provide support, in effect, to the boat from the relevant station. Again, is that fair?
A. That’s ideally what happens, yes. That is best practice.
Q. And in actual practice, is there a difference?
A. No, just sometimes the lifeboat would have departed before the launch authority arrives at the station. Every station is very different. But best practice, which is trained to our launch authorities, is having received the tasking message and paged the crew, we would then, whether it be by telephone or in person, have a discussion between the launch authority and the coxswain, and this is important because the commander of the vessel may decline the tasking.
Q. Yes.
A. So it’s beholden that the launch authority gives as much information to the coxswain as possible so they can form a plan, select their crew and determine who they are going to take and how they are going to execute the mission.
Q. Thank you. And on this question of declining the mission, you deal with that in the last sentence of paragraph 25. Again, is there any more detail you can give us there about the circumstances in which the search and rescue commander might turn down a request of this kind?
A. I think in most cases, if a SAR commander, ie the coxswain or helm of a lifeboat, declines a tasking that has been accepted by the launch authority it will be because, ultimately, the master of the vessel is responsible for the safety of the vessel and its crew and so in nearly — in most of the cases, if a SAR commander were to decline a tasking, it was because he or she feels it’s outwith of the capability or presents too much safety concern for him to act in that SAR commander role.
Q. And, again, this is — it may not be possible to give an answer to that — to this question, but do you have a statistical sense of how many requests are declined in any given year?
A. I don’t have that number, but it’s something that we are very alert to and keen to start to track, I think. But what I could offer is it is a rare occurrence.
Q. Yes, thank you. Now, once the lifeboat has been deployed, you explain in paragraph 26 that the coastguard will remain in communication with the vessel and any others involved to manage the incident. And on this, could we bring up, please, {INQ005204/1}, because this is your internal guidance on launch and recovery. And we won’t, again, need to go through the whole document, but I think this is the internal policy or guidance covering the process that you and I have just been discussing, isn’t it?
A. That’s correct.
Q. Thank you. It sets out the responsibilities, as we can see there, of the launching authority and, again, the processes we have been through in rather more detail here. Same question as before, I’m afraid. Is this guidance that was in place in force, as far as you know, in November 2021?
A. I believe it was, but I couldn’t categorically say so.
Q. Okay, thank you very much. Then another policy, please, which is at {INQ005206/1}, the launching of a lifeboat or other rescue craft. Again, the document, as far as we can see, is undated. Again, can I ask you: as far as you are aware, is — was this document/policy in force in November 2021?
A. I couldn’t — I really couldn’t give you a categoric answer to that.
Q. Is it — can you at least say that there would have been something which looked like it in force in 2021 in November?
A. Yes.
Q. Thank you. It sets out — do you see there under “Reason for Policy” that there is a rationale for a separate launch authority; in other words, a separation between those — that authority and those undertaking the actual rescue in order to provide — the words are — “an additional control”?
A. Correct.
Q. So does that take us to the point you were talking about earlier when considering the rare circumstances in which a tasking request is refused?
A. Yes.
Q. It needs that independent element for the person to form a view about, for example, safety.
A. That’s correct. What we’ve try to instill here is a three risk assessment process which would ultimately result in a lifeboat going to sea and potentially harm’s away. The first risk assessment is undertaken by the tasking authority, who have the picture of rescue demand in front of them and then say, “I need a lifeboat versus a helicopter”, for example. They will then task the launch authority, who had has a better understanding of the station, its capabilities, who’s on the roster — sorry, not on the roster; who’s available, the condition the crew, condition of the boat, will conduct a separate risk assessment and say, “I believe that is an appropriate use of the lifeboat, it is compliant and it is safe”, or during that period may well feed back to say, “I am prepared to launch the lifeboat, but I would ask for back up from a search and rescue helicopter or from another lifeboat”, for example, having agreed that, then give permission for the coastguard to page the lifeboat crew. And the final risk assessment is undertaken by the master of the vessel, who would make the final determination on whether to go to sea. It’s probably worth noting as well that it is possible for the tasking authority to task our lifeboats direct, so bypass the launch authority, but to do that, there would need to be a retrospective decision and agreement between the launch authority and the coastguard, and the times when they would do that were for immediate loss of — potential loss of life around persons in the water.
Q. So there is, as it were, a degree of flexibility in the system to allow for those urgent situations.
A. A small amount, but it still must be subject to the same decision-making loop, albeit retrospectively.
Q. Yes, and I think we will see — if we can go down to the bottom of this page, please, do you see the penultimate paragraph there: “A [search and rescue] unit commander will only be able to launch following receipt of authorisation …” But then another exception, which is the point we discussed earlier, whereby you can, as it were, self-launch in those circumstances for the purpose of saving lives to launch ahead of authorisation being passed, etc. So, again, there’s flexibility at that end as well.
A. A small amount, but if, for example, the coxswain was in a lifeboat station and saw something happen and decided to initiate a launch, which they can do, they — the first person they would call is the launch authority to seek permission to do that. The launch authority would then, in nine times out of ten, contact the coastguard and say, “We have just self-launched”, to what, why and where.
Q. Thank you. Then next, please, {INQ000666/1}, which is your standard operating procedure, launching authority response to a tasking request. It looks as though this is the procedure which governs the role of the launching authority; is that correct?
A. Yes, sir.
Q. And if we go to page 4, please, of the document {INQ000666/4}, it shows that this version, top of the first box, is dated October 2023, but there have been only minor text changes, if you see over to the right-hand side, since the version in October 2021. So it likes, doesn’t it, as though something very much like this was in force at the time of the incident in November 2021?
A. That’s correct, sir.
Q. Thank you. Just to complete this, if we could go to page 1 of this document, please {INQ000666/1}, you will see there that the “Objective” box explains the point of it: “… ensure the correct procedures are followed … in … response to a tasking request from a [search and rescue] Co-ordinating Authority.” Then on to page 2, please {INQ000666/2}, about two-thirds of the way down, it says that after the required information has been obtained, the launch decision must be compliant, achievable and appropriate. And, again, for completeness, can you give us an example of something which would not comply, be achievable or be appropriate? It’s been broken down in that way, as you see.
A. Yes, an example might be, especially with our in-shore lifeboats, which are restricted by certain criteria such as weather, endurance, wind strength and so on, it may be the launch authority — the coastguard would task an in-shore lifeboat, but the launch authority would say, “I don’t believe that’s achievable with the assets I’ve got” and would suggest you call an all-weather lifeboat to do that, would be an example.
Q. Thank you. Now, another policy, please, {INQ005203/1}. This is your guidance for co-ordination of search and rescue flank stations and on scene co-ordinators. Again, it’s undated, but would there be — as far as you know, would there have been a document of this kind in force, in place, in November 2021?
A. Again, I can’t be categoric, but I believe there would have been, sir.
Q. Thank you. And that — this document provides, as it were, an overview, doesn’t it, of the process for co-ordination in relation to search and rescue?
A. Yes, the role of a guidance note, as opposed to a procedure —
Q. Yes.
A. — is to give our volunteers more information around a procedure, which is something we are asking them to do in order to achieve a condition.
Q. Thank you. If we could turn on to page 2 in the document, please {INQ005203/2}, you see the first heading there is “On-Scene Co-ordinator” and it says there that where there are two or more vessels co-operating to deal with the same casualty, on-scene co-ordination will be required: “If a RNLI Lifeboat, Warship or SAR Fixed Wing Aircraft is on the scene one of these will usually assume the duties of ‘On-Scene Co-ordinator’ …” And confirms that those — those duties, I mean — it is the last sentence — are described in IAMSAR, Volume III.
A. That’s correct, sir.
Q. And then I think, finally, you will perhaps be relieved to hear, on policies and procedures, {INQ000664/1}, please, “Changing a Lifesaving Asset Service Status”. We don’t need to go into any detail on this, but again, can I just ask you if you can help. It is again undated. Would there have been, as far as you are aware, a document of this kind in place in force in November 2021?
A. I believe it would have been, but, again, cannot be categoric, sir.
Q. Absolutely. Thank you very much. Right. Let’s leave the world of policies, guidance and procedures and turn back to the history and, first of all, a bit of historical background — background to the particular problem of small boat search and rescue with which we are principally concerned. In your statement at paragraph 11, you deal with the RNLI’s experience — I’m sorry, it is page 11, paragraph 32 {INQ010101/11} — not in the Channel, but in the Aegean, and you set out there how you as an organisation received a request from, as it were, a parallel organisation, but this one in Greece, for assistance with the problems they were having to deal with in the Aegean Sea; is that correct?
A. It is, sir.
Q. And you were one of a number of organisations — you list them, the countries, in paragraph 33 — who all committed support to the Aegean effort and you, the RNLI, were asked to provide support to the Greeks on the island of Lesvos, which, as I think we all remember from news, of course, at the time, was a massive focus of this problem in the Aegean. And you set out there the simply huge number of refugees and migrants involved, with a very substantial percentage landing on that island —
A. (Nods).
Q. — and, indeed, the enormous number of people who died in their attempt to cross the Aegean. What was your, the RNLI’s, involvement in Lesvos?
A. So actually, I was asked to lead that intervention by my chief executive. We formed a small team and deployed out to Lesvos, initially with one reconditioned Atlantic 75, so a 7.5-metre bespoke search and rescue in-shore lifeboat, and the initial plan was to gift that boat to our Hellenic Rescue colleagues, provide them with a bare semblance of training on how to operate the craft safely, but it became very quickly apparent that they would need more support than simply a two or three-week intervention. So I was given remit to extend the intervention such that we took a second boat out, more training resource, and then left one of the RNLI trainers with the Hellenic Rescue Team for seven months, who did a magnificent job in training them to RNLI competencies.
Q. Thank you. And you explain in your statement that the support carried on for, I think, four years thereafter; is that correct?
A. Yes, that’s correct, to protect our investment and also there were a number of different stages to the intervention. The first one was it’s not just about providing a boat. We needed to provide the assets, train the Hellenic Rescue and then move them to a position where they were considered capable, credible, and then the final bit was sustainable. So as the intervention moved through the years of support, which was essentially two visits a year —
Q. Yes.
A. — we would focus on the capable, credible. And then finally, for example, we helped build their website so they could start fundraising for themselves and move into more — we trained some of their staff to be — train the trainers so that they could recruit themselves and train themselves rather than being dependent on a third party.
Q. Thank you. And you explain in your statement later on in 34, if we could have that on the screen, please {INQ010101/11}, that the result of all of that work was — this is just four lines from the bottom — that the HRT are now self-sufficient and considered the principal search and rescue provider to the Hellenic Coastguard. But you then go on to explain, as it were, the benefits in terms of learning for the RNLI. Could you just give us a little more detail about that, please?
A. Yes, I think the biggest takeaway we took from our work with the Hellenic Rescue Team is that no one piece of equipment, procedure survives contact with this type of rescue demand. It really is quite unique. It is by no means normal and it demanded constant understanding, constant adapting, constant evolving. The environment that surrounded this search and rescue was congested, cluttered, chaotic, especially in the Aegean Sea, given the relationships between Turkey and Greece, and that just made for a very complex search and rescue environment.
Q. Yes. You used the expression “by no means normal”, and it’s probably quite important for us to, as it were, stand back from this. Putting the Channel search and rescue work you have been doing now for many years to one side, what is normal for the RNLI off the coast of the UK? What sort of work do you do day to day?
A. Well, 98% of what we do right now over the past eight years is the 0 to 10 nautical mile space. We have seen a strategic shift recently from commercial offshore risk, large ships, fishing boats and so on, to much more rescue demand around leisure and in-shore risk. So there are more people using the beaches than ever before. There are more leisure activities than ever before. Every year there seems to be a new water-related leisure activity, whether it be stand up paddle boarding, open water swimming, kite surfing. All these present interesting risk profiles that we are constantly seeking to understand. So in trying to answer your question, the majority of what the RNLI do now is a mixture of either leisure-related risks. So this could be two children in a blow up swan heading towards France on a northerly from the UK to a yachtsman that’s in difficulty in bad weather, to a fishing boat that’s in difficulty, still. And increasingly, the biggest increase in rescue demand in recent years is around suicide and self-harm.
Q. But the obligation of the charity and of the law of the sea to intervene and help doesn’t involve forming any judgment about how the individuals you are rescuing got themselves into the situation from which you are rescuing them.
A. That’s correct.
Q. Thank you. So far then — just going back to the learning from this relatively long Aegean experience, did it lead to changes in your own training and procedures?
A. At that stage, no, sir.
Q. Did it, at a later stage, lead to changes of that kind?
A. Yes. Certainly from 2022 onwards, a huge amount of effort was put into that understanding that non-normal, what that means for our lay down, what that means for our training, our procedure, our equipment and the welfare of our crews.
Q. Yes. And when you — as we will go on to discuss, when you became involved in the Channel problems of small boat crossings, were you as an organisation able to draw on the Aegean experience?
A. I would say we did, sir, yes.
Q. In what ways? Can you explain?
A. We — the challenges that presented to the search and rescue assets in the Aegean were very similar to what was being presented in the Channel. The tactics of the organised crime groups in the Aegean we would start to see mirrored in the Channel. But fundamentally, the most important thing that we needed to do was understand the challenges that were being presented in the Channel and seek to come up with a whole range of activity to try and offer some tailoring to make sure that our stations that were being presented with this very abnormal rescue demand had the best training, equipment, procedure, support and guidance that we could muster.
Q. Yes. And just for completeness, as I say, in your statement, you explained about the experience in the Aegean and obviously your experience in the Channel. Does the charity have any other experience outside those two sea areas of this sort of migrant search and rescue activity?
A. Not that I am aware of, sir.
MR PHILLIPS: Thank you. Sir, would that be a convenient moment?
SIR ROSS CRANSTON: Yes. So we will come back at about eight minutes past. Thank you. (10.58 am) (A short break) (11.08 am)
SIR ROSS CRANSTON: Yes, Mr Phillips.
MR PHILLIPS: Mr Ling, we were talking about the experience the RNLI had in the Aegean and you in particular, but so far as the Institution is concerned, you talked about what you had learnt and how it came into play later when the small boat crossings in the Channel became a problem. Can I ask you this question about the Institution’s learning. Did you share that — the results of your experience with, for example, the coastguard or any of the other organisations involved in the Channel work?
A. Not that I recall, sir.
Q. Thank you. So then the history. We have touched on this, but let’s go back to it, please, at paragraph 35 of your statement on page 12 {INQ010101/12}. There you set out what we all know, the marked increase in small boat crossings from — you put it there at 2017, the first indications. I don’t want to go over all of the detail with you, but perhaps to focus on the graphs you have helpfully provided and the first, as you see on the screen there, is “RNLI Attended ‘Small Boat Crossing’ incidents”, and that graphically illustrates the increases so far as your organisation is concerned. Can I ask you a question about terminology. When you refer to “incidents” in this graph, are you talking there about the number of search and rescue taskings or the number of small boats?
A. Taskings, sir.
Q. Thank you. So is it possible then that within those numbers, there might have been more than one small boat rescued?
A. I couldn’t categorically say, but that would be my assumption.
Q. Yes. And as we can see, they — the incidents come dramatically to a peak in 2022 and then dip into ’23 and then further — obviously it’s year to date — to November in ’24. Does that reflect the greater number of assets and involvement of Border Force during those later years?
A. I would suggest there are two factors at play here, sir. The first one is, yes, the noticeable increase in assets of UK Border Force in — towards the middle to end of 2022 and into ’23. But also, I think, as a further graph would illustrate, that what we started to see were fewer boats crossing, but bigger with increased number of casualties on board.
Q. Right, thank you very much. Now, let’s come to some more of the detail, and it means moving on in your statement to paragraph 38 on page 13 {INQ010101/13}, first of all, because you here deal, first in prose and then in a graph we will come to, with the huge increase in the numbers of call outs. Just starting with that, you give the example six lines down of the Dover station going from an average of 25 service calls a year to 158 in the year with which we are concerned and what the result of that was; huge strain on staff, volunteers, their families and their employers. You then recruited more, but you deal with a much smaller community and indeed station at Dungeness, where they were going from 12 calls on average a year to nearly 100.
A. (Nods).
Q. And when we turn over the page, please, to the graph, page 14 {INQ010101/14}, we can see — if you can move it up a bit so we can see the whole thing, thank you — in 2021, November, the month with which we were concerned, was the absolutely peak month in those two years; is that correct?
A. Yes, that’s correct. I mean, of the 66 services you see there, 31 were undertaken by Dungeness, which is, as the Inquiry has seen, a very difficult place to launch and recover from —
Q. Yes.
A. — which is just a staggering effort from the crew.
Q. Yes. And in terms of the numbers of people per boat, there was also a remarkable change there that you tell us about in paragraph 39 on page 16. That’s the next page, please {INQ010101/16}: “The number of casualties that required rescue by the RNLI has increased. Whilst in recent months the number …” This is the point we have just been discussing: “… the number of services requiring RNLI response is in decline, the numbers of casualties crossing per boat has increased from an average of 13 per boat in 2020 to 53 per boat in 2024.” And we will come back to this when we look at events after November 2021 in a moment, but can I just ask you a couple of questions again about terminology. If we can go up to the top of this page, please, page 16, there is another graph and it is entitled “RNLI ‘Small Boat Crossings’ – Lives Saved”. Now, in the paragraph — we can just see the heading at the bottom there “Casualty Numbers Per Boat”. What is the difference in terminology?
A. If we — if the RNLI is tasked to a small boat with 40 people on board, we call any person that we are called out to, whether it be a yachtsman, a fisherman, a casualty. A casualty vessel and the persons on board are casualties.
Q. Yes.
A. It’s standard language that we use. And this particular graph here is highlighting a lot of our taskings were out to vessels that were outlined as vessels in distress and our remit was to make that distress or to take that distress away. And in most cases, that would be cross-decking from the small, unseaworthy boat on to the lifeboat, but there were some cases where we are tasked to persons actually in the water where the vessel has been compromised where we have categorised through a very stringent process of assessment that had we not responded and intervened, those lives would have been lost. So for 2021, we assessed, through a very rigorous process again, that we saved 50 lives around small boat rescue.
Q. Thank you. So just picking up a couple of points from that, please. So you as an organisation categorised, it sounds rather carefully and, as you put it, stringently, the difference between casualties, ie the people on each small boat in this example, on the one hand, and individuals in relation to whom you think it is appropriate to say this was a live saved.
A. Yes, so it’s people aided, yes, and lives saved.
Q. Yes.
A. And I would probably suggest those numbers do not bear accurate reflection to the lives that were actually saved, and that’s down to our process. An example would be if another vessel is in close proximity to the RNLI asset that’s undertaking the rescue, it’s difficult for our process to accept that a life was saved, because the other vessel may have been able to intervene. But they still bear a very fair reflection of the lifesaving activity undertaken around this.
Q. Yes. So in simple terms then, to outsiders, people slightly less stringent than you, the totals might be considerably higher.
A. I think that’s a fair assumption, sir.
Q. Yes. And just to complete my questions on this issue of terminology, can we go back, please, to page 6 of the statement {INQ010101/6}. There you use another term, which is “survivor capacity”. So not “casualty capacity”, “survivor capacity”. For — in practical terms, is that the same?
A. I would suggest that survivor capacity is engineers talking about casualties, whereas later on we are talking about we — how operators would consider them. So the survivor in, for example, the operational requirements for the design of a lifeboat will be a reference to: shall be able to house X number of survivors in self-righting mode. I would suggest that’s the difference in language.
Q. Thank you very much. So the — as I say, you have set out in your statement the history of these increases, not just in the number of small boats, but in the size of the vessels — or not actually the size; the number of people on board. And, again, if you can, going back to the time with which we are principally concerned, November 2021, what was the practical impact on you as an institution and on your volunteers?
A. I think September, October, November ’21 was quite a defining moment for the southeast Channel and the RNLI because we saw such an unprecedented increase in rescue demand presented in those three months. And the impact on our crews, who we have already discussed were used to a much lesser and more regular type of rescue demand presenting, was profound, both in terms of fatigue — because, of course, these numbers around tasking is just a number, but actually, if you unpack what that actually involves, so if I can give the example of 20 November, Dover lifeboat was tasked between 00.42 and 15.00 hours and did 11 hours 45 minutes at sea. That’s quite staggering, but it will be listed as three taskings. You know, an average — a tasking could take an hour, but more variably, the average is about three hours. So it’s very important to understand it’s not just the numbers of times. It is the nature of what we were doing. Some of the rescues were particularly harrowing, so we very quickly, certainly in ’22, started to focus in on the welfare of our crews. We started to see what I would describe as normalising the abnormal. In fact, I wouldn’t describe it; our medical director described that. And it was important to try and break that and recognise that this is not normal and that we need to have bespoke measures in place to look after the welfare of our crew. And then, of course, there was the fact that employers who were certainly used to releasing their volunteers and supporting our volunteers 12, 13, 14, 15 times a year were suddenly presented with their workforce going out for — nearly every day. And then also what we saw was the — was, which is unlike nothing else we have seen in the RNLI, that we had anti-social behaviour presenting towards our crews, which we — we wouldn’t experience anywhere else.
Q. And to be clear, you have never, as an institution, undergone that before?
A. Not that I am aware of.
Q. Can you tell us in brief terms what form it took?
A. Yes. So we have — we had verbal abuse to our crews, whether that be at the station, in the local supermarket, in the schools, walking down the high street. If one of our volunteers is self-employed and has a van with a mobile telephone number on the side of the van, that crew member would be subject to calls all through the middle of the night with people — you know, a concerted targeted campaign to keep him or her awake, giving verbal abuse. We have had golf balls thrown at lifeboats recovering back to stations. We have had death threats. We have had cyberattacks. We have had children being bullied in the playground because their father or mother is on the crew. Just a whole panoply of very nasty behaviour.
Q. To be absolutely clear, this, as far as you, the Institution, are concerned was caused by and in relation to your small boat work in the Channel.
A. That’s correct, sir.
Q. Thank you. And it had never happened before in the history of the Institution?
A. Not that we are aware of.
Q. Can you help with this question: is that still a problem?
A. It remains a problem, sir.
Q. And it was a problem in November 2021.
A. It’s when — I think it really first started to present in — I think it was most prevalent in 2022, but certainly started — I am mindful to share that on the — I think it was 24 November, Hastings, which operates a Shannon class lifeboat, again beach recovered and launched, had fishing boats blocking their exit to go and rescue, with a torrent of verbal abuse. So, again, to a volunteer who’s got up in the middle of the night to go and rescue men and women, it was a very difficult situation for them.
Q. And to be clear, that’s 24 November 2021?
A. Correct.
Q. Thank you. Now, we also know that in — from 2018, Border Force became significantly involved as a responder to small boat search and rescue operations in the Channel. Again, based on what you remember of the time, so between, let’s say, middle of 2018 and our period, November 2021, did that help to mitigate the strain on you and your crews?
A. I think it would be absolutely appropriate to say that Border Force rescue most of the casualties that present in the English Channel and I think consistently — I couldn’t be sure on exact date around 2018, but our data would suggest, you know, in excess of 90% of the casualties presenting in small boats are rescued by the Border Force, which again is hugely impressive.
Q. So that — I think what you are saying, therefore, is that they took a good deal of the strain.
A. They took — I think at the period you are talking about, 2018 to ’21 —
Q. Yes.
A. — they took up a degree of strain, but I think what we found out certainly in ’21 in the months of September, October and November was the spike in rescue demand presenting was simply unprecedented.
Q. And they were not able to cope?
A. I think it’s fair to say that all agencies involved in search and rescue at that time were very much under pressure.
Q. Yes. We have seen the figures. It was a particularly bad month.
A. Yes.
Q. Now, in your statement later on, at paragraphs 56 to 58, you talk about Border Force capability {INQ010101/23}. If we could have those two pages up, please, 23 and 24. Thank you very much. You express concerns there about assets availability and training. Were those concerns which pertained in November 2021?
A. I think in November 2021, most of the concerns of the RNLI, certainly the stations in the Channel, were around the lack of Border Force capability —
Q. Yes.
A. — capability not defined as a boat or an asset, but the ability to provide 24/7 cover/declared use to His Majesty’s Coastguard. I think from 2022 onwards, we started to understand, which — because 2022 was an exceptionally busy year, the shortfalls potentially that the Border Force had in terms of the type of equipment and the training of the staff on board the assets. And I think that’s linked to my comment from the Aegean that we learned, you know, that there has to be a bespoke approach to this; that a standard piece of equipment won’t survive contact with this type of rescue, and that applies equally to the RNLI.
Q. Yes. Well, as you have pointed out, indeed. Well, in 56, you will see at the top of the second page there you talk about the capability {INQ010101/24}. I think that means the assets and the training, the broadest sense of capability, and the availability, the resourcing point, was not bespoke enough to meet the specialist demands of small boat rescue, and then you say: “… and this also presents both risk and challenge to the RNLI.” And I assume you are talking about the situation as it was in November 2021.
A. Yes, I think that’s fair, sir.
Q. And what were the risks and challenges thus presented?
A. Well, I think the risk, the first risk, is that it presented a significant increase in tasking requests to the RNLI, which presented risks around crew well-being, fatigue, mental health. It presented issues to our assets as well because increased usage means increased maintenance and serviceability. And then it was just the risk of the effectiveness of an asset and people who aren’t properly trained in search and rescue trying to do a very difficult job under very difficult circumstances.
Q. Yes. And you say in — you make the training point in 57 and you make the assets, the surface assets, points in 56 and, indeed, in 58 when you talk about the nature of the vessels. They are not designed — and we can see a lot of evidence of this — for search and rescue work.
A. Yes, if you take a wind — what is essentially a wind farm support boat —
Q. Yes.
A. — with a wind farm professional skipper with some Border Force personnel on board and ask them to go out in the middle of the night in 1.5-metre sea and get alongside a small boat that could capitulate at any moment with 30 people on board, that’s a lot to ask of a non-professional mariner, search and rescue mariner.
Q. Yes, those are CTVs. We have obviously heard evidence, a good deal of evidence, about cutters, and we have been told that, of course, they were primarily law enforcement vessels. They weren’t search and rescue vessels.
A. Yes, and I think it’s fair to say that the Border Force at this time were uncomfortable with what was being asked of them, and I could recognise that and understand that.
Q. Yes. What difficulties did that create, do you think, in the day-to-day search and rescue work?
A. I think in November of ’21, there wasn’t perhaps as collegiate a relationship with UK Border Force, as you would expect from someone who was a fellow search and rescue partner. I think a lot of that was driven by the Border Force frustration with their role in small boat crossings. Even the smallest example that one of the crew gave me at Ramsgate was, “We would wave to the Border Force vessel when they went out, but no one would wave back”. So I think it was — it was a very difficult period. I think everybody was under immense pressure and all SAR partner agencies were struggling to cope with the demand that was being placed upon them.
Q. Can we then look at the question of the facilities available at this time in Dover, and this is something you talk about in paragraph 47, so going back, please, to pages 20 and 21. Again, if we could have both pages {INQ010101/20}. This is, as it were, at the end of the operations where you are disembarking the people from the small boats. Can you just explain in your own words what the difficulties were at the period with which we are concerned?
A. Yes. So in any other type of rescue activity outwith small boats in the Channel, the RNLI would execute a rescue and then co-ordinate with the coastguard as to what would happen around reception and onward movement. In most cases, we would hand over to the coastguard rescue team or to the emergency services. At this particular time, the principal landing point for small boat casualties was Tug Haven in Dover, and this presented, as I tried to outline, a number of problems for us.
Q. And you then go on to deal in 48 with the specific difficulties at Dungeness {INQ010101/21} and, again, just in your own words, can you explain what those challenges were?
A. So for those that don’t know, the Shannon class lifeboat is designed to operate at austere locations, beach locations, and is designed to launch on some very clever equipment into the sea and then beach itself, literally drive on to a beach, get hauled back on to its launch system and take it back to the lifeboat station. And that for Dungeness, in the context of small boat crossing, provided them the opportunity to beach casualties at Dungeness, a decision that would be made by the coxswain on a given day ostensibly around duty of care to the casualties he’s rescued, but also I think knowledge of the most expedient way to get the lifeboat back on service and available to go and be re-tasked was to offload my casualties at Dungeness lifeboat station and then offer myself to be re-tasked to the coastguard rather than sit in a queue, an effective queue, in Dover for hours on end.
Q. Waiting for the Tug Haven process to be completed?
A. Yes. If memory serves, the process then undertaken by the Home Office that every casualty rescued would have to be escorted by a Home Office officer on to — across the deck of a tug, on to the land when powers of arrest were issued, and that was invariably, with the resources they had, a very slow process.
Q. Yes. And you say fairly at the end of this paragraph, 48, that things have changed — we know that — and improved since this period.
A. Yes, and we reflected that in the direction to our crews to say — and actually got the crews to visit. So once Border Force land — put significant investment into Dover with a purpose-built facility that principally was around SOLAS, first of all, so humanitarian care, looking after the needs of the casualties and security secondary to that, we were very, very assured, as were our crews, that Dover was definitely the best thing we can do in terms of offloading our casualties.
Q. Yes, because in relation to Dungeness at the end of this paragraph, 48, you deal with the specific problems at this time in November ’21, that, as it were, reception on the beach effectively, which is what it is, was a real challenge.
A. Yes, I think because Home Offices resources were very stretched at that time, we didn’t — it was a challenge for the Home Office when we did — or for the coastguard when we did beach our casualties at Dungeness, and it is fair to say it was very chaotic, very difficult to administer any form of basic humanitarian care on a beach in such an austere location such as Dungeness. It was very chaotic at times, with other non-Governmental organisations wanting to offer support, some of which was helpful, some of which was unhelpful and unsafe. It was a very difficult time for the crew, the shore crew especially at Dungeness, who did a magnificent job.
Q. Thank you. Now, we talked earlier in more general terms about lesson learning, the learning you took from your experience in the Aegean. Can we look at how that was translated into guidance and policy within the RNLI by first looking, please, at {INQ006083/1}. This is your guidance for migrant movement. If we go to the end of the document, please, at page 5 {INQ006083/5}, we see it was last updated in April 2023. It’s version 8. It looks as though from the guidance review date that there would certainly have been a document much like this in place in force in November 2021; is that correct?
A. I can’t be sure of that, sir.
Q. Thank you. So far as page 1 is concerned, please, if we could go to that {INQ006083/1}, we will — you see in the — under the heading “Guidance”, there is an update in December 2018, the year, as we have discussed, when the problem really became significant. At the bottom of this same page, the final two paragraphs, are some important points of distinction: “Our stance …” The RNLI’s stance: “… which has been clearly stated to other agencies, is to satisfy our fundamental responsibility towards the safety of people at sea. We will therefore respond to occasions of distress at sea in the same way in these circumstances as for any other SAR situation. We will not judge our capacity to response based on the potential political or legal status of any casualties. “We are not, however, expected to be part of the wider immigration or border protection policies of the many jurisdictions in which we operate. That is the responsibility of other agencies.” So that is drawing, as I say, a very clear distinction. Was this guidance reflective of a problem in practice that you and your crews experienced at this time?
A. I would suggest — and I can’t recall, but I would suggest, sir, that this was offering that clear position and guidance to our crews, especially — especially at Dungeness, that our role is to save lives at sea and then return the casualties and seek to hand them over to a higher standard of care. At this particular time, Home Office policy was any casualty from a small boat that lands on UK soil is technically in breach of the law and will be arrested. So we had situations which were very chaotic, in the middle of the night, where Border Force couldn’t respond, a local police unit would be sent and suddenly we would have — a reasonably permissive environment on a beach where some humanitarian care was being given turned much more difficult situation to control with the arrival of a policeman who quite frankly didn’t know how to handle the situation. And that was just indicative of a lack of process or a framework to accommodate the reception of the casualties at Dungeness. So this, I believe, was an attempt just to clarify with our crews that, yes, there may be a legal position that Border Force would want and that we must — it was basically to say we are SOLAS first of all. We will not seek to go outside of the law, but our principal responsibility is to the casualty.
Q. Were there examples that you can now recall during this period where you were called out to — for non-search and rescue reasons?
A. Not that I am aware of, sir.
Q. Now, can we look at another policy, please. This is {INQ006089/1} and, again, this is local operating procedure relating to potential migrant service considerations. And if we turn to page 2 {INQ006089/2}, we can see that its original approval date was in November of 2018, again, perhaps not surprising given the history we have just been discussing, and there were various updates through to August 2022. Can I just ask you — if we go back to page 1, please {INQ006089/1} — were you aware of any other local operating procedures similar to this and dealing with this particular search and rescue issue?
A. It’s probably — trying to answer that question, sir, it’s probably worth explaining the role of a local operating procedure.
Q. Please. Thank you.
A. So a — there are two types of procedures in the RNLI; a standard operating procedure, which is a clearly defined process in order to meet compliance or safe operating, but there are some circumstances where a station may find it difficult to comply with a standard operating procedure because of local phenomenon or risks. So we set the conditions for stations at a very macro level to be able to come up with their own local operating procedure, which has a degree of governance placed over it so they can’t deviate massively from policy or procedure. But what this essentially is the station have undertaken a risk assessment exercise to say — in this case, I think it was Sheerness have identified, “It is possible. We may get involved in small boat crossing activity.” I think that’s unlikely, but nonetheless, they have been prudent enough to do some risk assessment planning and say, “If we are, this is the local procedure for what we do”. So in answering your question, I am not fully aware of how many LOPs were in place in November 2021, but essentially, this is a local risk assessment exercise.
Q. Thank you. If we go down on the page — we are only seeing part of it — you can see the text that makes good point you have just made. Can you go down to the bottom of the page, please? There. “LOP Sheerness”. So, as you say, this is for the station to do and it’s their own guidance.
A. And the reason why it’s been — we set — a local operating procedure must be reviewed and resubmitted for sign-off every two years, which is why you see the trail there.
Q. Yes, thank you very much. So leaving guidance and policy to one side and looking at the question of training and, again, bearing in mind the background of the experience in the Aegean we talked about, as the Channel incidents became more common — you remember the graphs — did you create or tailor your training — you have talked to us about general training — to address specific small boat problems?
A. We did, sir. That started in March of ’22.
Q. Thank you. So there wasn’t any special training for small boat rescue in November ’21?
A. That’s correct.
Q. Thank you. Did you, before the time of the incident, again, 23/24 November ’21, conduct any exercises within the RNLI specifically directed to the problems caused by small boat rescue?
A. Could you just repeat the date you include in that question, sir?
Q. Well, before the time of the incident, in other words —
A. Not that I am aware of, sir.
Q. Thank you. Were you — that you are aware of, were you invited to participate in small boat-specific training by the coastguard or anybody else?
A. Preceding this incident, not that I am aware of, sir.
Q. Thank you. We will come to the position more recently at the end. So then looking up to — looking now with a slightly increased focus to the immediate background to the night, could we bring up, please, first of all —
A. In fact, sir, can I just retract that last answer?
Q. I’m so sorry, please. Yes, please.
A. Because we did undertake a very small exercise with the coastguard and in particular the search and rescue helicopter, I believe, in October of ’21 in Milford Haven. I attended that exercise with one colleague from the southeast region and although presented as a mass rescue exercise, in essence, it was a proof of concept around whether a search and rescue helicopter could be effective in deploying a life raft to casualties in the water. The coastguard had developed a more — a slightly more detailed exercise intervention, including reception and staging on a beach and so on. Day one was doing some operational activity, talking about it, and what we highlighted was that the helicopter was probably ineffective in that concept of rescue. And then I believe on the second day — I wasn’t there for it — there was a workshop where we could start talking about the challenges that we were all seeing around small boats.
Q. Just on the date of that, you said you thought it was October ’21. Might it have been November that year?
A. It could have been, but the exact date I am not sure of. I thought it was October, but it might have been a bit later.
Q. Thank you very much. Well, now, looking, please, first of all, at {INQ000209/1}, we see there the minutes of a migrant red day meeting. You will be aware that these were meetings that took place pretty regularly in that month between the various institutions/organisations involved in the small boat rescue problem. This one, as I say, is 16 November. The RNLI is represented. The name has been redacted, but the initials are there. And you will see at page 2 {INQ000209/2} the RNLI representative raised a concern about — do you see — the first bullet point under “Saturday day”: “RNLI – overall – very evident that fatigue is playing a part in volunteers and crews – changing crews out – issues regarding employers – being managed – trying to address support.” It sounds as though this is a specific reference to the sort of general problems you were talking about a little earlier.
A. Absolutely, sir.
Q. Thank you. Then moving on, please, to the next one of these meetings, which is on 19 November, at {INQ000204/1}, I hope. Yes, it is. Thank you. This is another migrant red days meeting and, again, the RNLI is represented on the 19th, along with a much larger contingent of coastguard, including, I think, the man who was the chief coastguard at the time. If we go on, please, to page 2 {INQ000204/2}, there is a reference to busy days: “Very busy migrant day …” Etc. This is looking forward to the next few days. So a reference — do you see there — third line: “… assets might be fatigued on UK side.” And, again, is this just an example in writing of the sort of problem, particularly this month, that you have been describing for us?
A. Could you just direct me to where that is, sir?
Q. Yes, sorry. Do you see under “Very busy migrant day”? This is a presentation by a coastguard —
A. Yes.
Q. — officer.
A. I would suggest that was reflective of all the SAR partners —
Q. Yes.
A. — the coastguard, Border Force and the RNLI, yes.
Q. Yes, thank you. Then if we go down to page 3 at the bottom of the page, please — sorry, page 2, first of all. I am so sorry. And there’s the RNLI representative again: “… crew fatigue – all lifeboats crewed – no perceived shortfalls – only concern is Saturday morning but will be planning for this …” So in other words, an attempt to deal in advance with what was perceived to be a busy period and the problems of fatigue that you have been describing. Then over the page, please, to page 3 {INQ000204/3}, at the top of the page, the RNLI representative continues: “… going out proactively to stations to give them an idea of situation and looking at potential to plans for duty rosters over the weekend.” Do you see lower down in this same page we have on the screen the last full paragraph: “SW – Border Force …” That is Mr Whitton. And there is a reference in the second line. Do you see: “Standing up Ops Sommen from 0600 tomorrow morning.” So that’s the morning of the 20th. Was Operation Sommen something you were aware of at the time? Can you remember?
A. We were aware of it and we were concerned about it.
Q. Why was that?
A. Again, drawing on our experiences from the Aegean where this type — the pushback activity was undertaken, it suggested that in most cases, it presented an increased risk to the casualties in the boat.
Q. Okay.
A. I would say that I wasn’t aware of the tactics, the procedures, that the Home Office were intending to deploy, but the thought of trying to push back small, unseaworthy rubber boats in the English Channel was one that I think filled many of our crews with dread.
Q. And as and when it came into operation, did it have an impact on the RNLI or in its search and rescue activities?
A. That I can’t comment on. I am not aware, sir.
Q. Thank you. So then moving on, please, to {INQ000205/1}, and this is a different type of minute, not of a red day meeting, but a small boats update call. But, again, you can see RNLI representatives at the top there, the names redacted. This is 9.30 the next day, so the next morning, 20 November, and you will see at the meeting that the RNLI confirmed under “RNLI update” — do you see there: “Medium confidence for sustainability at Dover and Hastings for a 48 hour period.” And an additional full crew had been made available for a one hour’s notice deployment to relieve the fatigued crew. So, again, this is just a — it looks as though an example of what you have been describing, which is ways of keeping with the fatigue, with the stresses and the strains of this time.
A. Yes, that is right, sir, and at this time, I think we started to see the stations in the Channel provide — reach back to more central support such as critical key posts, such as SAR commanders, coxswains could be sent to certain stations to augment the normal station footprint to give them more resilience.
Q. Yes. So there were various measures being taken to deal with the continuous need for assets to be deployed for search and rescue.
A. Yes, but it is fair to say rostering volunteers is difficult because they are volunteers and their availability may well change. Their schoolchildren might have an accident and go into A&E and/or someone might have a particularly hard day or difficult day at work and needs take some time off. We can’t underestimate at this period as well that our crews were experiencing what we call red day stress, where we knew that there was a high likelihood of a crossing. We didn’t need an Op Deveran forecast for that. They are mariners. They can look at the weather forecast. It would change how they would operate. They would be reluctant to go outside of response times. They would cancel their plans, not go out to dinner, so on and so forth, and that in its own right over a period of time would generate a degree of stress. So it was a very difficult period.
Q. That presumably is just one of the aspects of managing a volunteer workforce, in effect.
A. Yes, the word “mandate” is one that you can’t really use in the RNLI —
Q. Yes.
A. — when we are dealing with volunteers. And we do make attempts to rostering and some stations do it very well, especially Christmas, for example. A lot of stations will come up with a roster to make sure we have got a lifeboat on service over Christmas. But over a period of time such as this, placed with the rescue demand, I — every effort was made to give assurance, but that’s why I think the language “medium confidence” was used. There was no absolute confidence.
Q. No, and it is an obvious point, but clearly there is a distinction here, isn’t there, between your organisation and the other people involved in the search and rescue work who were, of course, not volunteers, but they were all employees of, let’s say, Border Force, of coastguard, etc?
A. That’s correct.
Q. Thank you. Now, we have got, as I said, to 20 November and I would like to ask you some questions now, please, about the incident that took place that day when there was a refusal of tasking by the lifeboat at Ramsgate. Can we turn, please, to {INQ008562/1}. Now, that not very informative screen is part of a coastguard document and please take it from me it is an operational learning report in relation to the incident that took place that day, 20 November. If we could go on to page 2 {INQ008562/2}, please, and perhaps try and zoom in on the main — thank you very much. You will see under “Reviewer Observations”, there is a summary explaining that there had been a migrant incident, a small boat incident, that RNLI, the station at Ramsgate, were paged due to the UK Border Force being restricted due to working hours and only having the Valiant, the cutter, the Valiant, available and, further down, that the DLA — we have dealt with this acronym before, the launch authority — was said to have refused the tasking, stating, and I quote: “… ‘That if UKBF wont attend then we wont go afloat either’.” And in short, there was a later call explaining that the Border Force were not out due to restricted working hours and no asset available until 6.00, and at that point, the response — do you see about seven lines down, DLA responded as saying: “It’s UKBF not doing their job, we are volunteers. All their crew is paid to be out its getting ridiculous.” And then later: “… ‘If theres an emergency and youve got people in the water we will go afloat but at the moment I know by the sound of your voice that this isnt an emergency’ …” So were you aware of this incident at the time?
A. At the time in my previous role, I wasn’t aware of this incident.
Q. But you have come to be aware of it as a result of the Inquiry?
A. I have, sir.
Q. Thank you very much. And the report notes, as we will see, that the Dover MRCC had to wait for the Hurricane to become available at 6 o’clock in the morning. There was then a further delay and eventually, the small boat people were recovered by Hurricane, but, again, further time was lost. So just going over to the top of the page of the next page, page 3, please {INQ008562/3}, we will see under “First Receiver Comments”: “The issue with Ramsgate has been escalated with assistant director of policy & standards [it must be ‘at’] RNLI. It was deemed as unacceptable and RNLI has taken action to ensure this never happens again.” And then noted here that: As for [UK Border Force] asset availability, this is managed by [Border Force] on the basis of fatigue, end time of previous taskings and allowing enough rest time in between taskings. “Furthermore …” And then the point about delay: “… assets positioned in Ramsgate are bound by local tides. “… raised higher … with RNLI …” And a few paragraphs down, do you see at the bottom of this page on the screen, “Receiver Actions Completed”: “Agreed that RNLI will be providing HMCG with resource availability prior to days of significant migrant activity. RNLI managers have also [‘reassured’, that must be] HMCG that similar occurrences should not take place again and RNLI will respond to distress migrant incidents.” Now, this was clearly, at the time, a major problem as between Border Force on the one hand, RNLI on the other, with, as it were, coastguard as the co-ordinating authority in the middle; is that fair?
A. I would not see it as a major problem, sir.
Q. Thank you.
A. I think one has to understand the environment and the context around this occurrence, rare occurrence, but occurrence on a particular evening on 20 November. So as we have already discussed, Her Majesty’s Coastguard then, UK Border Force and the RNLI were under immense strain and pressure with quite unprecedented increases in rescue demand. This is towards the end of the month. Ramsgate undertook 16 taskings in that month, had a very busy month in September, 11 taskings in October. The crew were fatigued. The launch authority is empowered to do that risk assessment and determine if the request is compliant, achievable and safe. I don’t think the RNLI at this stage had fully understood the UK coastguard position that a vessel crossing the median line was a vessel in distress. I certainly, in my maritime standards role, wasn’t aware of that, I don’t think, until December when I attended a workshop with the coastguard in Dover.
Q. Sorry to interrupt you. Do you mean December ’21?
A. ’21, I beg your pardon, sir.
Q. No, no.
A. And there was some confusion about levels of distress, and I think we have heard that in evidence in the Inquiry. I am led to believe that the launch authority in question had been told that the vessel was underway, making way, under — in visual sight of a French vessel and casualties appeared to have life jackets. But irrespective of that, I think because the launch authority wasn’t assured that there was sufficient level of distress and out of concern for his crew and fatigue and probably mindful that there were some red days coming, it made a decision, which has a healthy amount of frustration attached to it, that, “We don’t believe the distress is worth risking our crew now”. However, and it is a very important distinction, if the situation were to deteriorate, he would sanction the launch of his crew.
Q. Well, I would like to take you to, as it were, the RNLI contemporaneous note of this in a moment, but before we do that, can I just ask you a question or two about this concept of distress, which was obviously, it sounds, a new one to you at this time. You said you first became properly aware of the way the term was being used in December that year, so after the incident. Is it a — that broad concept of every small boat being categorised as in distress, I take it then that that was something which was outside the experience of the RNLI.
A. I would suggest, and it is a suggestion, sir — I can’t speak for the crews, but I think, and we have heard this in evidence in the Inquiry thus far, there is — there are different levels of distress. And I perfectly understand the position whereby a small unseaworthy boat, overcrowded, in the busiest shipping lane in the world could be considered a vessel that’s very much in harm’s way. But I think what we also must recognise is a lot of our taskings were to vessels that were underway and making way and were not in what the RNLI would recognise as real distress.
Q. Yes.
A. However, it’s not the role and function the RNLI to determine distress. That — that is the mandate of the coastguard. So, as I said previously, I think what we saw here were a number of factors coming together around unprecedented pressure, new policies and procedures that weren’t properly understood, but I would still have to say that in this particular case, I would support the decision made by the launch authority, but would then seek to go back and provide that level of understanding. And I think that’s what’s referenced in the email below; that the RNLI management went to Ramsgate and clarified the position on distress and that, “We should do this and if you need support, we will get you support”, so on and so forth.
Q. Thank you. Can we look then at the RNLI’s note of all this, and that is {INQ010721/1}. There it is. Now, if you could just make that bigger, that will be excellent. Thank you. This is a series of entries on the day in question, the 20th, and do you see the first line under the main bold heading of the date, “Saturday 20th November”, etc: “Called to inform they tasked Ramsgate to a migrant activity and the LOM …” Can you help us with that?
A. Lifeboat operations manager.
Q. Thank you: “… replied that if border force aren’t willing to attend then nor are we.” And then, second box: “George from Dover [coastguard] called to chat through situation again with Ramsgate not launching. Situation in the channel is getting busy with crossings and he needs …” This is, again, coastguard: “… lifeboats out there with eyes on the situation. Discussed … briefing around letting stations have enough down time before the high risk day on Sunday but the two stations on/two stations off was not accepted and they need Ramsgate out there and wanted to speak to someone higher up the duty team.” Then below: “Called back to say had long chat with George at Dover. Situation still not resolved with regard to Ramsgate refusing to launch. Confirmed Boarder Force is out there. Will be calling Ramsgate LOM to discuss options.” And then I think crucially, right at the bottom at this time, 14.35, so the afternoon: “Called with update on Ramsgate refusing to launch from … this morning … Ramsgate … asked the question on initial tasking, ‘is there life at risk?’ the [coastguard] replied no hence why ramsgate refused to launch.” Now, is that context for the view you have just expressed that looking at it, as you are, with hindsight, this was a reasonable decision?
A. I — I will maintain that I would have — I would support the decision made on that night based on the context that was presented to the launch authority —
Q. Yes.
A. — the confusion over the levels of distress. I would be challenged by the language that it’s unacceptable for us to decline a tasking. It’s not unacceptable for us to decline a tasking. What we should do is justify our actions, and I think what you have seen here in some of the language used is a clear litmus paper indicator as to the stress and strain that was being felt at that particular time.
Q. Yes, that comes through very strongly, but it looks also, doesn’t it, as though the view that the Ramsgate operator formed was that they were effectively — the boat was being asked to, for example, looking at the second box, go out there and get eyes on the situation —
A. Which I —
Q. — which is not —
A. Which I would not recognise as a valid tasking request.
MR PHILLIPS: No, no. Sir, would that be a convenient moment?
SIR ROSS CRANSTON: Yes, I think so, yes. So just 10 minutes. Thank you. (12.06 pm) (A short break) (12.16 pm)
SIR ROSS CRANSTON: Yes, Mr Phillips.
MR PHILLIPS: So now, Mr Ling, looking then at the aftermath of this Ramsgate incident, can we look, please, at the minutes of the red days meeting on the 20th, so later that day at about 6 o’clock, and that is {INQ000220/1}. You will see again there were RNLI representatives present. If we could turn on, please, to page 3 {INQ000220/3}, the RNLI representatives are there recorded as making their contributions: “… challenges around Ramsgate – has been made clear that it is a distress situation if they are required they will launch.” So that looks very much the point you were canvassing just before the break and it looks also, doesn’t it, as though orders have come down probably from on high to convey that message to the relevant station?
A. I wouldn’t — I wouldn’t describe them as orders, sir. I believe what happened was local area management sat down with the Ramsgate crew and offered to give clarity on the situation around distress and our position and also offer support if we felt that Ramsgate was struggling.
Q. Thank you. Then the next entry, while we are looking at these minutes, another representative from RNLI: “… no issue with crewing – note – Hastings have had a significant amount of physical and verbal abuse from local fisherman.” So, again, this picks up the point you were describing for us, doesn’t it, that right at the time of the incident with which we are concerned, there was this problem of local abuse?
A. That’s correct, sir.
Q. Then moving on, please, to 22 November, so a couple of days later, the migrant red days meeting at {INQ000206/1}, please. And, again, a large number of coastguard present on this occasion, one RNLI representative. If we could go, please, to page 2 {INQ000206/2}, the RNLI representative is recorded — he is “AH”: “… No planned off service periods for his areas, Ramsgate and Walmer. (Confirmed with colleague during meeting – no planned off service periods from Dover through to Hastings).” So that seems to have been the situation in the immediate days before the incident. Then over the page {INQ000206/3}, he speaks or he is recorded as speaking again, and perhaps a flavour here of the background to Ramsgate. Do you see: “AH – Considering the email that’s been received from Border Force, are their assets available 24/7, are they restricted?” To which the response is: “… Assumes they are restricted for their ‘shift patterns’.” Again, it looks as though this is some of the context that you were describing earlier.
A. Yes, the individual there was responsible for looking after Ramsgate, and Ramsgate is slightly unfortunate insofar as where the lifeboat station is positioned in the marina, the Border Force vessels were tied up immediately in front of the lifeboat station, so there is no more graphic indicator of whether Border Force are available or not with an empty boat tied up with the lights switched out. And this was just another reference to say, or signpost, that the RNLI were very keen, especially at Ramsgate, that Border Force were able to deliver 24/7 coverage, not the restricted hours that they were offering at that time.
Q. Thank you. You will see the minutes continue with the RNLI person saying: “… Appreciate that Border Force are looking after their staff but worth noting that the volunteers that are being requested to launch also have day jobs. Going through the night in not uncommon.” Again, that’s the point you were making to us earlier, to which the response from coastguard, actually — Border Force weren’t actually in attendance at this meeting — is: “… MB will have the discussion with Border Force, and we appreciate the commitment of volunteers.” So it looks — how can I put this — as though both sides are trying to reach a way —
A. Navigating out of stormy waters, sir.
Q. Thank you very much. Much better put. Thank you. So just then turning to the night itself, can you confirm, so far as you are aware, that none of the RNLI stations serving the Dover Strait were off service that night?
A. That’s the information I have, sir.
Q. And to your knowledge, again, were all of those stations therefore available for tasking?
A. Correct.
Q. Thank you. But standing back from what we have looked at now, the evidence you have been giving, the documents we have been looking at together, at the time of the incident, is it fair to say then that the RNLI and its volunteers, along with the other organisations involved, were under very significant pressure due to the increased number of small boat crossings, the increased number of taskings and, in the case of the RNLI, the extra strain put on your volunteers by the abuse that they were facing?
A. Yes, I believe that is the case, sir.
Q. In relation to the specific Ramsgate incident, are you aware of any subsequent refusals by RNLI stations to launch for a small boat rescue?
A. I am not aware of any. We do have — we don’t track decline of tasking. As I mentioned earlier, it is something we are probably going to look at in the future, but I am not aware of any, sir.
Q. As far as you are aware, now having had the chance to look at this material, on the night in question, 23/24 November, all your stations understood the requirement to launch in response to tasking for small boats in distress.
A. Yes, sir.
Q. And, as we can see, that the coastguard had been assured that that was the case.
A. That’s correct.
Q. Were there, as far as you are aware, again having now seen the material, any resource pressures preventing crew from being tasked on 23/24 November?
A. Not that I am aware of, sir.
Q. And were you aware of any other reason why RNLI might not be tasked that night?
A. Not that I am aware of, sir.
Q. No. Is it right that no RNLI lifeboat was tasked to Incident Charlie during the period 23 to 24 November?
A. I understand Ramsgate was tasked in the evening of the 24th to what we now know was tragically the search for missing people from what has been characterised as Incident Charlie.
Q. But not earlier in the incident, if I can put it that way.
A. That’s correct, sir.
Q. Thank you. Right, thank you. Can I now ask you, please, some questions about the speed of response of your lifeboats. Here we are going back to another part of your statement and paragraph 7.1, so {INQ010101/2}. Now, here you explain in 7(i) that: “The RNLI aims to reach at least 90% of casualties within 10 nautical miles of the coast, within 30 minutes of a lifeboat launch and can deliver [search and rescue] cover out to 100 [nautical miles].” You explained earlier, didn’t you, that the vast majority of your activity is in the 0 to 10 range? And, as you know, the Inquiry has asked you to consider and provide some estimates for the likely speed of response on the night in question. We know it’s hypothetical because we know that the RNLI, during the currency of the incident, was not tasked. So can I ask you first: the likely response time for the Dover lifeboat to deploy, if it had been tasked at about 1.28, so about 1.30 in the morning on 24 November, going at — let’s use the expression “best speed” to the co-ordinates 51 degrees 04.9 north, 001 degrees 58.04 east.
A. I don’t have the timings against the co-ordinates. I’ve got time — they have been plotted against the co-ordinates, but I have referenced them slightly different, sir.
Q. Please explain. Thank you.
A. So what we have done in trying to answer your questions is take the average launch — the average alert time, so that is when the coastguard first paged the DLA, the launch authority —
Q. Yes.
A. — which for Dover is 2.6 minutes over November. So there is a discussion period — or from the first initial launch authority page to the crews being paged, 2.6 minutes. The average launch time for Dover over that period was 20 minutes, so that’s crew mustering, briefing, boat leaving. We then allowed five minutes to get out of one of the busiest ports in the world, because we are restricted in our speed and what we can do there.
Q. Yes.
A. And then we can proceed at safe space. We estimate, as an indicator, to get to the Sandettie Lightvessel would be a total time of 73 minutes from that first launch authority page.
Q. Thank you. So just picking up a couple of points on that. When you said “safe space”, I think you probably meant “safe speed”.
A. Safe speed and space, yes.
Q. Thank you.
A. Yes.
Q. And the point about Dover, you had to get clear, for your Dover station, of the port at Dover —
A. Yes.
Q. — just as we have heard the Valiant had to on the night.
A. Yes, it’s in similar parlance to the airline world. It is controlled airspace.
Q. Yes.
A. So we have to seek authority to slip the berth because there is such a — it is busy traffic with the cross-Channel ferries. The lifeboat is restricted by speed, even on a service response call, and once we are out of the outer harbour, then the coxswain can make best speed and, in doing that, may well seek certain permissions to cross the shipping channel, for example.
Q. Yes. And in terms of the time to get clear of Dover, how have you factored that into your 73 minutes? Have you taken, again, an average allowance of time for that process?
A. We have just approximated. Sometimes it would be quicker than that —
Q. Yes.
A. — but if a ferry was arriving at a particular time, we may be given a hold restriction. So we have averaged five minutes as a — as a reasonably realistic time.
Q. So five minutes to get clear in Dover, okay.
A. At which point we could then increase our speed to between 20 and 25 knots.
Q. Yes.
A. And for a distress tasking, the coxswain will do — will always operate at safe speed, but will be looking to push the lifeboat.
Q. Yes. And presumably, once you are out, once you are clear of Dover, you are making your way across the Channel towards the Sandettie lifeboat — life buoy — Lightvessel, I’m sorry. There are a number of variables which will determine the actual time it takes, for example, the weather; correct?
A. That’s correct.
Q. Nodding doesn’t work on the transcript.
A. Yes, it does. Sir, that’s correct. So these times have been calculated by coxswains themselves given the weather information provided in the MAIB report, so they have taken into consideration tide and wind direction and visibility on the night that was given to them in the question. So I would suggest they are reasonably accurate figures based on their knowledge of the local area and how they would operate. What it doesn’t account for is having to slow down or take avoiding action for shipping.
Q. Yes, what I would describe as a non-mariner’s traffic.
A. Yes.
Q. And that must be another important variable, surely, on any given tasking.
A. Indeed it is, sir. So the lifeboat will be working very hard at this stage to proceed at best speed, but do so safely and in compliance with international regulations for the prevention of collision.
Q. Yes. But, again, that’s something which, by definition, is very difficult to predict. In comes the tasking. You just have to do what you can with the seaway conditions as they are.
A. That’s correct.
Q. Yes. And what about times of day or night? Does that have any impact on the timing?
A. We have assumed it doesn’t. I think the boat works harder at night because you don’t have the advantages of daylight, but that area is very well lit with navigation buoys and we have navigation equipment on board. We have radar and we have crew who will be detailed to look out of the boat as well, so lots of means to ensure we can operate quickly at night.
Q. Okay. And when you have been doing this calculation, what lifeboat or what class of lifeboat have you been using for the purposes of the example?
A. We have made a prediction from Dover using its 17-metre 7 class lifeboat, all-weather lifeboat. We have made an estimation for Ramsgate using their 14-metre Trent all-weather lifeboat, which came in at 75 minutes. So pretty much the same times for Dover and Ramsgate.
Q. Yes.
A. And Dungeness have estimated a time of 103 minutes, so one hour 43, much further to the west.
Q. Yes. And taking those three examples, what — and bearing in mind your — the table in your statement and the discussion we had earlier about capacity, what you call in the table survivor capacity, taking the three vessels you have just talked about, what would their — where would they feature in your table? Shall we get the table up, please? Page 6 of the statement, paragraph 15 {INQ010101/6}. Where would they fit in, the three vessels, to this table and, therefore, what survivor capacity would they offer?
A. So the Shannon class at Dungeness, which had the one hour 43 response time —
Q. Yes.
A. — would offer 43.
Q. Yes.
A. The Trent class is not listed here. I would need to get that information for you, but it’s in the region of 40 to 50.
Q. Is that the one coming from Dover?
A. Ramsgate.
Q. Ramsgate, thank you.
A. That’s an omission on our part, apologies. And the 7-class, which is at Dover, has a capacity of 96.
Q. But again with the qualifications we discussed before. So that this would involve large numbers of people on the deck, as it were, rather than inside?
A. Correct.
Q. Thank you. And can I ask you another question. Have you done any similar work to produce a likely response time, an average response time, a similar time in the morning 01:28 for your assets to deploy to the median line at the closest point to the UK search and rescue region boundary?
A. I have assumed by that question, sir, that you’re talking relative to the lifeboat station?
Q. Yes.
A. Okay. We have, sir. For Dover the time from — again same criteria — first page being given to the launch authority, assuming launch times, exiting port, Dover would be 50 minutes. The same criteria for Ramsgate would be 67 minutes and Dungeness 52 minutes.
Q. And again, I think we can take it as read that that, as it were, average calculation is subject to all of the other variables that we have already established in relation to the first calculation?
A. The best that we can, sir, yes.
Q. Thank you. And all of the same points about survivor capacity, the point on the screen, in other words the nature of the lifeboats, the amount that they can take self-righting and non-self-righting?
A. That’s correct, sir.
Q. It would be helpful if you could supply details to the Inquiry of the Trent-class figures, as it were adding another line to this, to this table. That would be very helpful.
A. We will get that to you, sir.
Q. Thank you very much. Clearly you, assisted by the experts, the coxswains have been doing a good deal of thinking about this, are there any other average speed journeys that you have looked at and can give us assistance with?
A. We were asked to consider times to the median line at the closest point to the Sandettie Lightvessel.
Q. Thank you.
A. Again with the same criteria, which I won’t repeat unless you need them, sir?
Q. No.
A. Dover would be 76 minutes, Ramsgate would be 78 minutes and Dungeness would be 106 minutes.
Q. Thank you. In terms of variables, there is one point I should perhaps have asked you about. Of course your — and you have described this for us very vividly — but your volunteers are, certainly during the day for most of them, working at their actual jobs and in the calculations therefore in assessing an average speed of response, does it make a difference to that what I would call perhaps old-fashioned word, the mustering of the volunteers when the tasking comes in?
A. Yes, I think it’s fair to say that a crew being woken up in the middle of the night might generate a slightly longer response team — time than someone that was wording in the butcher’s just around the corner from the lifeboat section. They are awake, they are close. What we have done in the times we have got here is taken the average launch time for the entire month of November. So in the case of Ramsgate 50% of its tasking in November, in September, October, November was daytime, 50% was nighttime.
Q. I see.
A. So it’s a reasonable average metric to use.
Q. Right. Thank you. Now moving on to the events after the distress calls were received, after the involvement of coastguard and then the Valiant in what became known, as we have discussed, Incident Charlie. You have indicated that you are aware that the coastguard were — that the RNLI, I am so sorry, were tasked as part of as it were the search for survivors, the missing, etc, after the small boat had been discovered by a French ship in the Channel. Just to complete the factual picture, can I ask you, please, to turn to {INQ000320/1}. This is not an RNLI document, but an extract from the coastguard ViSION log. If you look at the header incident header “X-Ray 2”, multiple persons in the water was the, as it were, the heading, the name for the operation that we have just been discussing. And you see Gris-Nez, the French side, requesting assistance and above the line you can see that the incident was opened at 12:58, do you see that?
A. (Nods).
Q. If you could turn, please, on the screen to {INQ000320/6} of the document, again, just to trace the 12:39:13 3 RNLI’s involvement. Do you see there at 13:37:32 Dover ALB also tasked and the — that looks as though it’s a reference to the Dover all-weather lifeboat?
A. That’s correct, sir.
Q. Thank you. And looking at an entry below that in the middle column the shorthand is given, do you see there: DRALB. So RNLI resource DR3, launch requested, and again it looks as though these are references to that lifeboat. If we can go back, briefly, to {INQ000320/1}, halfway down the page under “Details”, you will see DR3 is the third asset listed there and a summary of its involvement is set out. Called 38, tasked 13.41, proceeded 13.41:47, and then released actually very shortly thereafter. And if we go to {INQ000320/7-8}, of the document and have them both on the screen at the same time, please, we can see, do you see, various entries on the left-hand side, references to DRALB and then going forward to the entries at 14.21:11, so we are now at the bottom of the second page, page 8, you can see I think that the Dover lifeboat is assigned to one incident, cleared from another; in other words, it’s cleared from this incident, which is 041497 and assigned to another incident. If we could now please have pages 8 and 9 of the same document side by side. {INQ000320/8}. So just moving on a page, thank you very much. Looking down at the very last entry on page 8, so that’s the left-hand side, do you see in capitals: “Dover lifeboat were not assigned to the [person in the water] search being coordinated. They were placed into this incident as a reference point whilst they were steaming out towards the MPC buoy. They have now been released from the incident placed into a more appropriate incident for their tasking.” Is there any — is there any light that you can shed on the circumstances that are being described there?
A. Not with more detail, sir, no, sorry.
Q. Thank you could we then turn to another record, which is {INQ000660/1}. This is one of your documents and we will see it deals with the same incident, so probably more familiar. Date of incident, do you see, and time there, 24 November, 13.40, and about halfway down, if we could have the full page of the document, please, “Record details”, “Narrative”. We can see the Dover lifeboat was: “Launched to reports of a vessel in the MPC area [with] 30 [persons on board] … On passage passed [Border Force] Hurricane with 2 empty vessels. Found inflatable …” Etc. And: “Spoke with [coastguard] and agreed return to station.” And it looks as though the timing of all of this, and do you see the two incident numbers three boxes down, the first one that we looked at and then the second incident to which it was tasked, it looks as though this is describing the same deployment. And you note there: “Whilst boarding [this is in the narrative] could see SAR activity in distance in French waters. Spoke with coastguard and agreed return to station. Discharged at Tug Haven and returned to station.” Now, going down into the detail under “Request”, time when crew were paged/alerted 13.40 and then time lifeboat launched nearer the bottom of the page, three boxes up: 13.40. How would that be achieved?
A. I think that’s clearly an error, sir.
Q. I think it must be.
A. Yes.
Q. It’s certainly better even than the averages you have put forward?
A. It would be, sir.
Q. Yes. If we turn on to {INQ000660/3}, towards the top of the page, the second box there, if we can — thank you. Situation and action, where and when, time arrived on the scene, you see 14.17. So about 37 minutes to get to the scene by the look of it. If we go over the page, please, to {INQ000660/4}, outcome and close. There the time back to the RNLI station 16:40, but lower down, time depart from the scene/search location 14.29. So in terms of involvement in what I am calling the post-event, the X-ray 2 tasking, that was the limited extent of the Dover lifeboat’s involvement?
A. Yes, sir, that’s my understanding. I should probably caveat my previous answer as well by saying it is possible that the lifeboat launched within a minute because at this particular time, the crew could have been in the station —
Q. Yes.
A. — training or just knowing that because it was a high-risk day, often the crew would cut out the middle bit and just go and drink tea in the station.
Q. Yes.
A. I would need to confirm with Dover about that, but I just thought it worthy to offer that caveat.
Q. Yes, yes. Well, obviously if they are actually there on site, as it were, then precisely the point we discussed earlier about the need to gather the volunteers from their jobs or in the middle of the night no longer applies?
A. Yes, and that does often happen at lifeboat stations.
Q. Yes. Could we then move to the Ramsgate lifeboat tasking for the same event and that is {INQ000320/1}. Again, it’s another coastguard document, it is the same document we looked at before. You will see there under “Details”, do you remember we looked at this for DR3, here we have RG3 which I think is the Ramsgate lifeboat, and the details of its involvement: called at 19:02, tasked at 19:06, proceeded at 20:00, on scene 27 minutes later, released just before midnight. Again, turning to {INQ000320/14}, we can see the details of this. The initial tasking, three entries from the bottom, RNLI resource RG3 launch requested. Do you see that?
A. I do, sir.
Q. Then over the page to the top of the {INQ000320/15}, an explanation of the background to that. The second entry: “Based on the search plans above and the fact that some of the migrants were wearing life jackets – Ramsgate lifeboat is being tasked to carry out the search of this area.” 12:47:34 4 At 19:06:33 further down the page, it’s the penultimate entry, do you see “DLA approved launch”?
A. I do, sir.
Q. So again thinking of the example at Ramsgate we had just a few days before, the answer this time was yes. And 12:47:54 9 then {INQ000320/16} at 19:12:16, again it’s the penultimate entry, tasking of Ramsgate ALB, UK Coastguard involvement in the incident. And then at the very top of the next page explaining that — sorry, we should have started at the bottom of the previous page. I am so sorry, can we go back to 16. Do you see there’s a discussion here recorded, I suspect it’s a coastguard decision, and right at the end: “Decision made to task Ramsgate … to search UK section – 3hr search 34% to cover possibility without depleting assets for red day …” So it sounds as though there was some understanding and consciousness there that an eye had to be had on what were predicted to be heavy days for crossings the next days. Is that a fair reading, do you think?
A. I couldn’t categorically confirm that, but I would deduce that from reading this narrative. can see the RGALB is proceeding. Search instructions 12:49:19 3 passed. And then on to {INQ000320/18}, please, 20:27:31 RGALB, do you see in the middle of the page there: On scene. So it’s arrived at the designated point. Then for completeness on {INQ000320/20}, at the very top of the page, please, 23:59: Released. So that’s the end of the tasking. If we can just look at the equivalent RNLI records as we did before for Dover, they are at {INQ000662/1}, please. Here we have the Ramsgate lifeboat internal report. Under “Narrative”: “[All-weather boat] launched to assist in search for persons in the water from a capsized migrant RIB [Southwest] of the [Sandettie] area. Area searched but nothing found.” Under “Request” further down the page, the time the crew were paged and alerted was 19:05 and the lifeboat was launched, if you look further down the page: Time lifeboat launched 19:24. And turning over the page to {INQ000662/2}, at the top there: Finish time of incident 23:59. Thats what we saw before. It looks therefore, doesn’t it, as though Ramsgate went out in the search but found nothing?
A. That’s correct, sir.
Q. Thank you. Now, Mr Ling, moving then from the time of the incident to bring matters more up to date. As we have seen from the graphs the problem — and as we all know the problem of small boats is continuing to this day and the Inquiry is aware that there have been changes in the resourcing of that response, I mean at its broadest level in questions of primacy. For example we know that in 2022 the Ministry of Defence was given primacy for small boat crossings. It later went back to the Home Office and we know that further assets were deployed, you have mentioned this, both by Border Force and indeed by the MCA in terms of their aerial assets. You have also said, and we have seen it on the graph, that your involvement in terms of taskings has decreased certainly in ’23 and last year 2024?
A. (Nods)
Q. So that’s the background. What I would like to do briefly, if I may, is to take you to the graph we saw before but looking at the later date so we can just see all of that. So could we start, please, on page 15 of your statement, {INQ010101/15}. This is within paragraph 38. As I said, we looked at it earlier but we can see very dramatically illustrated the much lower totals for ’23 and ’24 in terms of number of people aided and, as far as you’re aware, has that trend continued into this year, into 2025, since the statement was made?
A. It has, sir. We have been tasked but again the trajectory is downward.
Q. Can we take it, it seems obvious, that that has reduced pressure on the RNLI and on your volunteers?
A. It has, sir.
Q. Are there at the time we are now talking, in March ’25, are there the sorts of strains and resource pressures that you have vividly described as pertaining in November ’21?
A. No, sir, with the exception that the rescues that we are undertaking are increasingly more complex with higher numbers of people involved and some of them remain very harrowing, and by that I mean persons in the water not transferring from a small rubber boat to the lifeboat.
Q. So that although there are fewer incidents, if I can put it that way, they create their own very significant challenges?
A. Yes. I think it’s fair to say there is a very healthy amount of — when we’re tasked to what is a small boat incident with persons in the water, whilst our lifeboat crews are in a much better position than they were perhaps in November 2021 there is still a lot of trepidation. One coxswain would say, “It’s the shouts that keep me awake at night.”
Q. And in terms of just to confirm something you said earlier of the other features of RNLI experience or life in November ’21, I think you said that the problem of abuse of various kinds of you, as an organisation and your volunteers, still pertains in March 2025?
A. It does, sir.
Q. So the decrease in your actual involvement hasn’t led to an end to that?
A. It hasn’t, sir, no.
MR PHILLIPS: No. Sir, I am going to move on to another topic now. Would this be a good moment?
SIR ROSS CRANSTON: Yes. So we will come back this afternoon?
MR PHILLIPS: We will.
SIR ROSS CRANSTON: Yes. So about 1.55 this afternoon. Thanks very much. (12.55 pm) (The Lunch Break) (1.56 pm)
SIR ROSS CRANSTON: Mr Phillips.
MR PHILLIPS: Now, Mr Ling, the next series of questions I want to ask you about are under the general heading of RNLI changes since the incident. The first I want to ask you about is restructuring, ie the restructuring the organisation itself. Can we have your statement, please, {INQ010101/25}. Thank you. At paragraph 59, you explain that in ’22, the organisation underwent organisational change and restructuring and part of the restructuring included the creation of your current role; is that right?
A. That’s correct, sir.
Q. And you give the aim of this in the next sentence which was: “… to improve support to the delivery of RNLI lifesaving across all of the [United Kingdom] and Ireland.” Was any part of the restructuring down to lessons learnt from this incident in November 2021?
A. No, sir. This — this restructuring had been planned months in advance of that.
Q. And in relation to your new role, however, you indicated that you took it up in February of ’22 and your principal responsibility was to understand the rescue challenges of small boat crossing in the Channel, etc. So it was a major part of your job, at least.
A. That’s correct. On my first day, both the chief executive and the director of operations made it very clear that this should be my main effort to start with.
Q. Right. But what I think you are saying, therefore, is although that was your main responsibility, you know, in the job, the creation of the role was not itself due to the small boat incident in November 2021.
A. That’s correct.
Q. Thank you. Was it — is it fair to say more broadly that the restructuring was caused by/due to the more general problem of small boat search and rescues in the Channel?
A. No, sir, it’s not fair to say that.
Q. It was simply the way you had to focus when you started in post.
A. Yes, the focus of the RNLI at that time was to deliver more autonomy to the six regions within the RNLI, which each had a head of region. And at that time, we already had a head of lifeguards. We had head of water safety, but we didn’t have a head of lifeboats to co-ordinate lifeboat support activity from the central elements of the RNLI to support the regional delivery.
Q. Thank you. So that was changes in terms of your own structure. The next topic in your statement that I would like to ask you about is to do with developing equipment. In the next paragraphs of your statement, 60 to 66, you have explained to us that the RNLI has developed equipment specifically by way of response to small boat incidents. How did you go about that?
A. The first thing we did was listen to our crews. So in my first weeks, myself and the operations director visited all the southeast Channel stations and it’s fair to say we — we had some very robust discussions where crews were able to communicate the challenge that they were under. So the first thing was to build that link between the strategic RNLI and those on the frontline of small boat rescue. That gave us, as you can imagine, a huge amount of information on the challenge and as I tried to articulate in my evidence there, we then set about a process, which is ostensibly, first of all, how to stop casualties drowning in front of us, which to a lifeboat crew is — or to any crew, but especially to a lifeboat crew, is something that doesn’t really happen, with the exception probably of the Thames. And that was because we were presented with mass persons in the water, and so we needed to buy time in order to enact rescue, and that required the development of some lifesaving apparatus, which you will see in the report as LSA.
Q. Yes. And you explain in paragraph 60 that you conducted some trials at Poole at the base or headquarters, rather, and developed two products for consideration. And I will ask you to say a little about both of them in a moment, please, but is this fair: that based on the consultation process that you have described undertaking with the people actually on the frontline, these were — this was equipment that, as it were, they wished they’d had and you were now developing so that they could have?
A. I think that’s fair to say, sir.
Q. Okay, thank you. So can you take them in turn, please? And it may be sensible to look at the way it’s dealt with in your statement. Do you see the first item there halfway through paragraph 60, the horseshoe flotation device?
A. Yes. So we are very lucky at the RNLI College. We also have a state of the art sea survival centre. So in March, within a matter of weeks of the department standing up, we invited some industry partners to come to our sea survival centre. We had volunteers from the headquarters give up their day to get in a wetsuit and act as casualties all day in the water. And we started doing some testing evaluation and basically gave industry line of sight to the challenged faced by small boat and mass person rescue, and they worked alongside with — developing very quickly by incentivising industry. They did the hard work for us and they came up with two modified products which were available. And the first one is the horseshoe, which is a very small device, about so big, and this is an auto-inflate device. That’s a picture there {INQ010101/26}.
Q. Yes.
A. And this, at this point, was quite a significant breakthrough for us. We worked with industry to develop it slightly and then we deployed that within, I would say, about two months, and our all-weather lifeboats were then issued with 50 to carry —
Q. Yes.
A. — and our in-shore lifeboats carry 12 of these.
Q. Yes, we see that at the end of paragraph 60.
A. And this is a proven lifesaver.
Q. Well, you give an example there of its first use in action at the end of ’22.
A. That’s correct, on December 14th, yes.
Q. Thank you. Then the second piece of equipment, please —
A. Yes.
Q. — rescue —
A. The second piece of equipment is something we refer to in the RNLI as the doughnut, which was an existing product. It was a light aircraft — life raft carried by small aircraft and it was designed for three people and, yes, if you have a floor in the bottom of it, you can put three people in it. It is very unstable, but it gets them out of the water. But if you took the cover off and removed the floor, put more handrails on, we found in our Poole testing that it could keep up to 27 people afloat. So, again, in the context of multiple persons in the water, a very significant piece of lifesaving apparatus, which again has been proven to save life.
Q. Yes. Well, again, you give an example there in August 2023 at the end of paragraph 62.
A. And our crews — ALBs carry three of those, sir.
Q. Thank you. So this is — as you have described, this is the RNLI producing its own pieces of, as it were, bespoke equipment for precisely this sort of situation. Are you aware because of your work, continuing work, in this area of any bespoke equipment of that kind having been developed by any of the other stakeholders involved in search and rescue?
A. I am not aware of any from the UK stakeholders, but obviously in our work in the Aegean, we were — I don’t know whether to say exposed or had sight of a huge range of innovative ideas around the same challenge of stopping people from the sort of things you would probably see at a beach resort; that people get towed between a speedboat, to other similar types of equipment, long rescue tubes that casualties could put their arms over. But I wasn’t aware of any being operated by our colleagues in the UK.
Q. No. So there were foreign search and rescue organisations who had their own, as it were, bespoke equipment?
A. Yes.
Q. And is — the process that you have described in your statement of consultation, working with industry developing, the product and then, you know, deploying, is that a continuing process? Are you working on other products at the moment?
A. Yes, we are, absolutely. We continue. I think what we have learnt is we must continue to learn, continue to evolve, continue to adapt because the way that the rescue demand presents is adaptive. It is changing. It’s not constant. So, again, having developed a way by which we could stop people drowning in front of us, the next challenge I set after our first mass person in the water exercise was how to get people out the water quickly, because a challenge the RNLI has, which sounds quite strange, is we do struggle to get lots of people out of the water quickly with our current equipment and lay down of the lifeboat.
Q. Yes.
A. We partnered with a company in America called FunAir, who make all sorts of inflatable platforms for the super yacht industry, and we sent them some initial diagrams of the sort of thing we wanted and the effect and the outcomes we were seeking and they quickly drew some scribbles in a notebook and converted them into a design, which we tested again in April again, in another mass person in the water exercise that we hosted. And that proved to be a game-changer for us because existing means of getting casualties out of the water would be about one person per minute at best speed, but SeaStairs, which is a platform with sinking stairs, allowed us to get two crew members at sea level, which is much more efficiently ergonomically. And we can also use a film of water almost to slide casualties, even if they’re unresponsive, on to a platform and therefore get them out of the water quickly. In our testing, we could get 20 people out in 90 seconds.
Q. So a huge improvement.
A. Massive and, again, a proven lifesaver on a number of occasions now.
Q. So this is already in use?
A. Yes.
Q. Can you give a rough date for when that came in?
A. Yes. SeaStairs was deployed on October ’23, I believe.
Q. There we see it being used on the screen. Do you see you refer to it in your statement at paragraph 66 {INQ010101/29}?
A. Yes. So it is a rapid blow-up attached to the side of a lifeboat.
Q. Yes.
A. It can be manoeuvred alongside a lifeboat as well.
Q. Yes.
A. What is out of picture there are some sunken stairs. What we’re finding, I think you heard from your SME expert from University of Portsmouth yesterday, is that after a period of immersion, the casualties will lose a lot of strength in their limbs, especially their outer limbs. So this allows us to literally grab them, slide them on to the platform and get them on to the lifeboat.
Q. Thank you. So far then as other changes since the time of the incident, I would like to ask you some questions now, please, about the multiple persons in the water protocols that you have been developing, again which you talked about in your statement, and the starting point is really what you tell us in your statement at paragraph 39 and particularly the graph you have produced on page 17, if we could have that up, please, {INQ010101/17}. We can see the graph. Do you see per boat — it is the graph on the right.
A. Yes, sir.
Q. There is a remarkable increase from the average number of 28 in 2021, the year with which we are principally concerned, to now, going up and up and up to 53 last year.
A. (Nods).
Q. And I think it’s right, isn’t it — and you explain this in paragraph 39; we have it on the left-hand side — that although, therefore, the number of call outs, shouts, has gone down, the number of people per boat has dramatically increased and part of the — one of the ways of dealing with this is the protocol that I have mentioned? In your statement, you talk about, in paragraph 41 — if we can go to the bottom of that page, please, on the right {INQ010101/17}, thank you — this issue, the mass persons, the multiple persons in the water issue invites three responses. I would like to ask you a little bit about each one, please. First, you say that you require accurate information on casualty — by which we know you mean people in the vessel — numbers as soon as possible from the coastguard. We have heard a good deal of evidence about the difficulty of getting information about small boats. Are you now, in 2025, receiving an adequate level of information on that topic from the coastguard?
A. I think the quality of that information varies and it depends on what assets are available to provide that information. So by way of an example, if fixed-wing assets or rotary assets are able — are probably the best means of identifying those numbers, but as we have heard from previous witnesses, the levels of distress on board are very difficult to quantify until you arrive on scene because of exaggerated calls or positions, and so on and so forth. So unlike any other type of SAR that we do, when we’re going out to small boats, we really don’t know what we are going to arrive upon.
Q. And that is still the position now?
A. That is still the position now, yes.
Q. So in terms of gathering information, it sounds as though you would agree with a number of other witnesses that the best source of information is air cover.
A. Absolutely, when the air cover can provide that.
Q. Exactly. And — or, rather, but the — whatever the air asset can observe, there are still the uncertainties that you have mentioned in terms of levels of reporting about this question of urgency, about this question of, to use the term we were talking about earlier, distress.
A. Absolutely. So what we don’t know is the level of distress on board, the condition of the vessel —
Q. Yes.
A. — if it’s about to be compromised. Is it taking on water? Are there injured parties on board? So yes, it’s very much being tasked into the unknown, which is why we try to and have trained our coxswains not to commit to rescue immediately on arrival, but to take time to assess the situation and provide situational awareness back to the coastguard.
Q. Yes. In terms of looking forward from today, is there anything else that you can think of which might assist on this particular difficulty?
A. No, I think the coastguard and our other SAR partners are doing a valiant effort to get us that information because, of course, that’s key information that they need. It was just to make the point that it is so very important to us, when we are talking about a vessel carrying 80 casualties, which we have experienced and been tasked to, as previous discussions have highlighted, that’s outwith the capability of some of our lifeboats, so an incident response is to start tasking — asking for back up.
Q. Yes, as it were from the off.
A. Yes.
Q. So the second response you mention in this paragraph is for active engagement between the RNLI and the coastguard at point of tasking to consistently consider dual tasking, the very point we have just been discussing.
A. That’s correct.
Q. And, again, from your point of view, as things are now, is that process being handled satisfactorily?
A. I believe it is, sir, and only a couple of weeks ago, both Dover and Dungeness were same — tasked with the same asset, which had 80 casualties on board.
Q. So, in other words, rather than one at a time, they are both being called out to the same boat?
A. Yes.
Q. Thank you. Then the third point, you say at the end of this page: “Finally, the risk invites the RNLI to continue to develop contingent procedures …” If we can read on, please, to the next page {INQ010101/18}: “… with a rescue demand/persons in the water that equates to over twice the capacity of a single asset.” This is the point about the vast increase in numbers of people on each vessel. And if we could turn over, please, to page 27 of your statement and paragraph 64 {INQ010101/27}, you here deal with the development of training and procedure around triage, and you go on to give detail in this part of your statement about the development of what’s now, I think, known as the multiple casualty in-water triage tool. A bit of a mouthful, but I’ve got that right, have I?
A. You have, sir.
Q. Thank you. Now could we look at that, please, {INQ009006/1}, and there is what I imagine is a card, is it?
A. Yes. There’s two sides. There’s a flowchart and there’s a check card, yes.
Q. Thank you very much. And is this the version currently in force, as far as you are aware?
A. That’s — this is not the one that we use. The one that we use is modified against that.
Q. Okay.
A. So I would recognise this — as the SME from Portsmouth University outlined yesterday, ours is very similar to that. It’s probably worth explaining and giving some context to that answer, sir.
Q. Yes, please.
A. That having identified ways to stop people drowning in front of us, the next priority was the issue of triage —
Q. Yes.
A. — and, therefore, in October of 2022, we held a desktop exercise where we invited the coxswains up from the southeast stations. We had a medical director present. We had legal — our legal present and we had some operating experts present. And I set a desktop scenario of Dungeness is tasked. 60 people in the water and 20 are face down. What are you going to do? And, brutal as that sounds, asked the coxswains each what they would do, and the first question went to the coxswain of Dungeness, who said, “I will go for the people face down first”. So we then started a journey of behavioural change and explaining why and the logic behind to say that wasn’t what you should do, because if you do that, more people will drown and that we need you to go for people that are showing signs of life, visible signs of life, because they we know we can rescue, whereas a person face down is a big unknown because we don’t know long how long they have been face down.
Q. Yes, it is counter-intuitive —
A. Correct, and it was.
Q. — but it is the right way.
A. And this, as I said, was in October of ’22. Then on 14 December 2022, we had a mass drowning event off Dungeness where the coxswain then said, “Had I not received that coaching, more people would have drowned”, because that very situation presented where he transited past face down people in order to rescue and get people who were demonstrating that they were alive. So we quickly — we had a very early validation of our approach. There was no other procedure in place, so we developed our own, which wasn’t this. It was a similar — it was a check card, but basically around that premise that when you arrive on scene, you step back. You assess the situation. You prepare the LSA, because once you have committed to rescue in a mass person in the water situation, you are fixed because casualties come at you from all angles. You can’t then interact with those that might be drifting away. It becomes very, very difficult. So our coxswains are now trained to assess the situation, deploy the LSA, come up with a plan, identify those most vulnerable and then commit to rescue and, again, that has proven to be a lifesaver. What then happened was we sought to get this kind of position endorsed, because there was no other guidance and there were some challenges around that, around the use of language and so on and so forth. So we did a lot of work to try and quickly align and set the conditions for a permissive document or check card that would be recognised by ourselves, recognised by the coastguard, potentially used by other SAR partners. We were made aware of the work that was being undertaken by the SME from Portsmouth yesterday, who then — who — there were three people.
Q. This is Professor Tipton?
A. Professor Tipton, yes.
Q. Yes.
A. So there are three SMEs working with the coastguard who were developing this tool. We were given access to it in April.
Q. April of which year, sorry?
A. ’23.
Q. Yes. We can see their names. If you look carefully at the bottom, there they are.
A. Yes. So we called an extraordinary meeting of our medical committee to try and get our head round this and our need for a unified position on mass person in the water triage. Dr Morgan joined that meeting, so was very, very helpful. As a result of it, we adopted a very similar, very similar, flowchart, still with our extant checklist. And as Professor Tipton said yesterday, Dr Morgan then presented that at the IMRF in June of that year. I — we were present at that meeting and —
Q. Again, just on acronyms, could you explain that one, IMRF?
A. International Maritime Rescue Federation.
Q. Thank you.
A. So a body ostensibly in Europe, but there was a huge gathering in Rotterdam of specialists to talk about —
Q. Yes.
A. And one of the key areas being talked about in June of ’23 was mass rescue.
Q. Thank you.
A. So we then had a — we then amended our document again, sent it to our principal SAR partner, the coastguard. We had a meeting with them where we aligned planets and had an endorsed portion on the use of the check card and language, and we subsequently deployed a revision to our original check card out. So very long answer, but in short, from January of ’23 to October ’23 was the journey of change to the document you see in front of you.
Q. Thank you very much. What I am going to do is to trace some of what you have said using documents.
A. Okay.
Q. So this one, as you have rightly pointed out, looks as though it is the —
A. Morgan/Tipton/Sheppard.
Q. Exactly, that academic team. Can we now look, please, at {INQ009669/1}. This is, I think, your check card; is that right?
A. That’s correct. It is two-sided, but that’s the front side.
Q. Exactly. I think it very succinctly describes exactly the process you have just outlined for us. Assess the scene, so pause —
A. Yes.
Q. — take it in; scan the area; assess the non-swimming or floating casualties; and then the key point, rescue. Not them. Don’t go to them, but go to the swimming or floating casualties with airway above the surface.
A. Yes, and that is the key thing. It’s airway above surface.
Q. Then if we turn over the page, please {INQ009669/2}, that’s, as it were, the backside, and here is your version, at the bottom of the page, of the Tipton diagram we looked at.
A. Correct. So you see it is slightly different.
Q. Yes.
A. In all intents and purposes, the flow — the check card, what you have just run through, is probably what the volunteers would use. What we have done here is offered a comparison to the Tipton/Morgan/Sheppard.
Q. Yes. And then just to complete the documents that you have, I think the next one is {INQ009670/1}, which is the flowchart, and you can see that’s your document.
A. Yes.
Q. And, again, this gives the same steps, just presented in a slightly different way.
A. That’s correct, because as you have seen already, we do have rather a lot of policy and procedure guidance, so on and so forth, and so in this respect, we wanted it to be really simple: two documents, one that talked about the process, and a check card that’s on board the lifeboat that the crews will use when they’re tasked with small boats.
Q. As far as you are aware, are these two documents I have just shown you, the RNLI documents, the ones that are currently in force?
A. They are, sir.
Q. Now, just picking up the comments you made about Professor Tipton, you have referred to his evidence, which you are obviously aware of, and I am sure you also know he produced a report for the Inquiry, and that’s {INQ010283/1}, 8 December last year. Could we go, please, to page 22 {INQ010283/22}. I take it you have had a chance to look at the report.
A. I have, sir.
Q. Thank you. Page 22, please. Here he deals with the development of the triage tool, the thing you have just been describing to us for mass rescue incidents, and explains the development there and how it went, the conference in Rotterdam, at paragraph 4.15, that you have told us about, and then the further work that took place. And there on the next page, please {INQ010283/23}, is his triage tool at the time of this report, which is, as I said, the end of last year. Going back to page 22 and 4.15 again {INQ010283/22}, you see in the fifth line, he says: “I was not involved in the development of the RNLI tool, but it appears to be identical to the earlier version of [huge acronym], presented in Rotterdam.” The understanding we have, and I think this is what I took from your answer, is that although he wasn’t directly involved, you were very much drawing on his and his colleagues’ work in the development of your own triage approach; is that fair?
A. Absolutely. His colleague, Dr Morgan —
Q. Yes.
A. — who provides medical director support to the coastguard, which is why that role was key for us, was involved in a meeting that shifted towards this new revised model.
Q. Yes. Now, there is one point he has raised here in 4.16 about your approach and the distinction between what he saw as your approach and his own, where you see the second line: “… we added the ‘Airway Observed to Submerge’ [box or heading] to the box containing ‘Purposeful Signs of Movement’ …” And that’s not something he thought that you had at that point done. Have you taken that on board and will you make that change?
A. Almost certainly we would make that change, but we need to check that, because when we checked with the coastguard on this, they advised there’s been no change to the document. So there’s definitely a need there to make sure that we have — we are always checking version control.
Q. Yes.
A. I am reasonably — in fact, I am very comfortable that the check card we have got right now remains fit for purpose and still reaches out to the caveat that’s been put here in 4.16.
Q. Thank you very much. Now, the Inquiry has received a good deal of documentation which shows that the RNLI has liaised with various other stakeholders in relation to this triage approach, this policy. What I would like to do is just to see if we can find a document which captures some of this. That is, please, the extract at {INQ010722/1}. Yes. Well, I hope we can make it rather bigger, but still be able to read the whole thing. Maybe that’s not going to work. If you just, yes, stop moving there and so we can see the whole of the text of the box on the right, please. Because this is — it’s a coastguard document. It’s not your document, but it looks as though this records various discussions and exercises from an action tracker for the Dover Gris-Nez Collaboration Forum, and here, do you see we have various entries from September ’22? If you go to the left of the document again, we can see what this is about: “Discuss [multiple persons in the water] triage.” And then back again, please: “Share plans in place, outcomes of exercises and any other information as required to ensure that in the event of such an incident both MRCCs can work collaboratively and effectively.” It looks as though what we see there is, as it were, not the rolling out exactly, but the discussions over the years, as you have just been describing, between you on the one hand and the various other stakeholders about this approach.
A. Yes, I think it’s probably worth adding a little bit more colour to this entry —
Q. Please.
A. — sir, and say that as part of the — improving the situation, which started with the new department standing up, in February of ’22, there was a need to improve strategic liaison between all of the SAR partners involved in small boats, and that resulted in a forum which started in July, which was hosted by the coastguard at Dover.
Q. July ’22?
A. July ’22.
Q. Yes.
A. But principally then we had the Royal Navy, the coastguard, UK Border Force maritime, I think UK Border Force land and the RNLI at the strategic level talking about issues relating to small boats. And it was agreed that we would not only continue that forum every six to eight months, but we would also establish an operators forum where coxswains, masters of the Border Force vessels, Border Force maritime could meet again to talk at a very operational level, share learnings, constraints and issues, and that forum was established as well.
Q. So just to step back a bit from this, the discussions which we have seen evidenced here about the triage system were part of a much broader engagement with your fellow stakeholders which you, as the new head of lifeboats, instituted; is that fair?
A. I think — I wouldn’t want to position that we instituted. We asked for strategic liaison. At that time, as I have signposted before, the relationship with Border Force wasn’t as close as it could or should have been, considering we were both involved in the same activity, namely search and rescue. But I think, and I am sure our SAR partner colleagues would endorse this, that the increase in liaison actually meeting for whole days and talking about some of the issues had a demonstrable effect not only on relationships, but also sharing of best practice. And I signpost in my evidence that we shared our learnings from our Poole testing and equipments, which were embraced by Border Force and the Navy. So our liaison moved into a completely different space.
Q. Yes. Well, let’s see some more examples of that, if we may, briefly. {INQ005147/1}, please. Here is “Small Boat Crossings Tactical & Operational Response Forum. Again, it is a coastguard document, but you will see, for example, the second entry at 2: “AH …” I think that’s an RNLI person: “… to lead interagency exercising/training of maritime crews following approval of the casualty triage tool and relevant policy.” And then right at the bottom of the page: “MB – to liaise with John C. and identify if there are any obstacles in arranging joint exercising on the water between [the small boats command] & RNLI. “This has been resolved and joint exercising should go forward as required.” Can I ask you on that: have exercises between the two organisations taken place?
A. No, sir. What has taken place is of the three mass person in the water exercises that we have hosted at Poole where we put lifeguards in the water and we test policy, procedure, equipments and techniques, both the coastguard, the Home Office and industry are all present and invited to those exercises. So there is a healthy amount of information sharing that takes place at those forums, but what we weren’t done, as I think I have signposted as well —
Q. Yes.
A. — is we haven’t done a properly set up exercise between all parties.
Q. Is that something you think ought to be done?
A. Yes, we believe quite strongly it should, and it is our intent that — our next mass person in the water exercise, which is scheduled for September of this year, we have extended an invite to Border Force to provide an asset and people, and so hopefully there is the conditions there to do that in September. But we believe quite strongly we should be doing it.
Q. Yes. And are you aware of what the obstacles might be in the way of doing it to this point?
A. No, I am not sure I do know. There are obviously some challenges around doing that; optics, availability of resource, somebody taking ownership to design the exercise. What would the outcomes be? What resources are involved? It is quite a huge undertaking, but I think it’s something that we could and should do.
Q. Thank you. Moving on, please, in time to December ’23, {INQ005148/1}. Here, again, minutes of an event, this time involving not just UK institutions/organisations, but also the French. There was, it looks like, a very significant meeting between the two sides also attended by the RNLI. If we can go to page 2 {INQ005148/2}, please, and section 4, which turns out to be a very long section indeed, it looks as though there was a presentation here to the assembled stakeholders precisely about the mass casualty rescue triage and equipment that you have been developing.
A. That’s correct, and in addition to this, we have hosted our French counterparts at the RNLI SNSM and, again, one of the key topics when they came to visit us were sharing of mass rescue techniques, protocols and equipment.
Q. And we can see at the bottom of page 4 of the document, please {INQ005148/4}, the request is made by the UK to arrange for your tool and check cards, the ones we have just seen, to be shared with the French coastguard. Is that something that was done, as far as you know?
A. I am not sure, sir.
Q. No, thank you. And, again, moving on, please, to last year, and this is {INQ005159/1}. This is your document, “Multiple Person in the Water Triage”, 1 February. It refers there, you see, to trial triage procedures used by the RNLI. I just wanted to check with you. This is February ’24, as I say. Were they still being trialled or are they now firmly and formally in place?
A. I think we strongly believe — and it’s actually in response to a point raised by Professor Tipton yesterday when he mentioned that he hasn’t received any feedback on the effectiveness of this — we can offer in this Inquiry feedback that the triage works and it saves lives. So we — and we believe we fed that back, but we will certainly do so as a result of the evidence that was presented yesterday in a more formal way. I think what this was doing was bounding how we use this until we have a healthy amount of confidence that it does work, but as we can see from events that happened only a few weeks ago in the North Sea, okay, we need to make sure that we can roll this out now such that it could be employed by any lifeboat station as we have done with similar developments in the Channel, whether it be equipments or first aid procedures.
Q. As far as you were concerned, has this triage in practice saved lives?
A. It has, sir.
Q. Can you give an example?
A. Yes. I think the most telling example I would give was a tasking in August of 2023, when Dover lifeboat had 46 casualties on board already from small boats. It was then alerted to a Mayday person in the water situation around six miles off Calais. The lifeboat then crossed the traffic separation scheme, went to the scene, and was met with multiple persons in the water. The coxswain, who had received, who had been on the mass person in the water exercises at Poole and received the training, followed and executed a textbook rescue whereby he assessed the situation, he deployed lifesaving apparatus — both the horseshoes and the doughnuts — he then left the casualty group to go back to another casualty group that were in the water, did the same process and then started to — then committed to rescue. Sadly people died on that particular shout. But the 7-class embarked 86 casualties of which 10 were categorised as very seriously injured, including those that required oxygen therapy. The coxswain then headed — declared to the coastguard, as per the checker, “I have now embarked my maximum number and I now have to leave the scene to preserve the lives of those I have saved.” Passages back to Dover. During his transit of the shipping channel he lost an engine, he managed to deal with that, got the lifeboat back and all the casualties he rescued survived. But key as well were that before he left the scene he deployed all of the other equipment he had on board such that he could buy time for French SAR colleagues to come and rescue other people. So that, in our mind, was a very — and he actually wrote to us afterwards and said, “Had I again not had that training or this check card, or these equipments many people would have died that day.” So we have had some very powerful validation of our work.
Q. Thank you. I should have had said, by the way, it’s entirely my fault but this is an MCA document, not an RNLI document. Then moving further forward in that month to 5 February. Can we look please at {INQ005150/1}. Another discussion, this time again involving French representatives, and again if we can go to the bottom of the second page, please {INQ005150/2}, the RNLI sharing the check card that you were working with, the one we have already seen, again, a long discussion which goes on for many pages to page 6 {INQ005150/6}, please, and a summary there. Do you see what the RNLI’s representative is recorded as saying: “Anything we can do that gives ours crews reassurance that they are doing right thing and that there’s consistency so that they know whether it’s a CTV from Border Force or a vessel coming from France is operating in at least a similar way will reassure them. Happy to help but also interested to see what you are doing to see if we can improve what we are doing.” So the point, as I see it, you are making there is, “This is what we think is the right approach. It gives our crews reassurance, but we would like the further reassurance that you are doing something similar.” Is that fair?
A. Yes, I think it is, sir. I think there’s two requirements that are captured in that paragraph there. The first is the need to continue to develop interoperability skills; train as we operate, operate as we train with our UK SAR partners. And an example of that would be if we declare what we call a safe haven, so the scenario I take you back to that at Dungeness, Shannon has been launched. There are more people than it can physically embark on a boat/we have a contingent procedure whereby we will deploy the lifeboats/life rafts. Thus that we can get people out of the water, prevent them from drowning, have the sick inside the boat, as many as we can on the deck, but also use the life rafts tethered to the lifeboat, and we call that a safe haven. We would then call the coastguard and say, “We are no longer lifeboat. We are a safe haven and we require immediate back up.” We haven’t exercised that concept yet. We have not exercised the concept of Border Force coming alongside to extract casualties from a life raft. I would bet quite strongly that’s what we will be doing in September of this year, but we haven’t done it. It is just one example. Then the second thing I think that is captured is increasingly, we are being asked to operate in French territorial waters now. As I said, we did that 42 times in 2022. So I think there is an implied task there to be working again with our French colleagues and develop more procedure to support joint operations in either the UK or French SRR.
Q. Thank you. Well, that deals with the procedures and the triage. What about the question of the equipment, just briefly going back to that? As far as you are concerned, is there any reason why, for example, Border Force surface assets shouldn’t deploy the items of equipment that you have developed?
A. I understood — I can’t confirm it, but I understood in the summer of 2022, having shared our equipment and our understanding of its use with Border Force and the Royal Navy, that both organisations undertook procurement activity not through the RNLI, but through our industry partner. I also have been led to believe that the Home Office or Department of Transport have sought to share some of the equipment with the French coastguard.
Q. But as far as you are concerned, if they haven’t, as it were, started using these pieces of equipment, they ought to.
A. I would suggest — I would struggle to find a reason why they wouldn’t want to use it.
Q. So then going back to the French side of all of this, please can we look at {INQ010722/1}. This is the document that we were trying to make sense of before. It is the last entry that I am concerned with at the moment. Do you see: “As for the MPIW process, this is not something to be adopted by French, but definitely something for SMC’s and French rescue units to be aware of as procedure.” Thinking about the position now, so nearly a year later, as far as you are aware, have the French side decided to adopt this process?
A. I couldn’t comment. Sir, I don’t know.
Q. You don’t know. Again, based on your experience, is it something that they should do?
A. Again I don’t feel empowered to offer comment on that. But I would say again that for the RNLI, the check card is working.
Q. Now, can I go back to your statement on this at paragraph 73, page 32, {INQ010101/32}, where you are dealing again with multiple people in the wear. You say: “Unlike the land environment, there is no real policy or legal framework to support triage and rescue for a mass person in the water event. Going forward, the absence of such policy may present a legal risk to search and rescue agencies responding to such incidents. The RNLI would welcome the development of a framework that provides a legally permissive environment for mass person in the water SAR.” Can you just help us all to understand, what do you think is missing and what do you need?
A. So if we were to take the land environment and look at the learnings for example in the Manchester bombing event, there is a framework, a legal framework, for first responders which gives them clear direction on triage and allows them to deviate from certain protocols that for a normal response would be insisted upon an example of that might be CPR. So while that framework exists in the land environment, in the maritime environment, it doesn’t exist and I think that was signposted by Professor Tipton yesterday.
Q. Yes.
A. Thus when we have gone and responded to multiple persons in the water, including people face down, if we were to operate whereby if we have interacted with the casualty who has drowned we then, under normal rules, would seek to do everything to survive that casualty. So that would probably include putting a rescue breath in, undertaking CPR and once we have, under the law, once we have started and initiated CPR we can’t stop it until a clinician has told us to stop. In the context of being in the middle of the Channel with seven people on a lifeboat and 40 people in the water, you can understand the challenge that presents. We need every hand to be pulling people out of the water and therefore coming up with a framework which, which would survive contact with any legal challenge later we think is very important.
Q. How, in terms of the formalities of it, would this be done? Would it be an amendment to the IAMSAR manual or something like that for example?
A. I –I don’t think I’m well placed to offer that guidance other than to say I think ultimately it would be something from the IMO or IAMSAR or something that was recognised by UK government really.
Q. And has the RNLI sought to persuade its UK government partners in this to take this forward?
A. The RNLI has not sought to lobby the Government on this. As Professor Tipton signposted yesterday, that process we believe had started by sharing and seeking endorsement through the IMRF.
Q. Thank you. Now, in terms of training and exercises, again bringing the position up to date, you deal with this in your statement from paragraph 68, if we have that {INQ010101/30}, please. There and later in your statement you talk about the importance of training involving not just your organisation but other partners. Do you think that there’s more to be done on that front, as you sit here now, in March 2025?
A. I think my answer to that, sir, would be so long as people are still crossing in small boats and the risk still exists the requirement for training remains as real as it does now as it was back in 2021/22. So the answer is yes, sir.
Q. As far as you are aware, are there arrangements in place for future joint exercises, future joint training?
A. Not that I am aware of other than the signposted intent that we will be holding a mass person in the water exercise in September of this year and have extended a formal invite to Border Force to participate.
Q. But as far as you are aware then, there are no initiatives from your stakeholder partners for joint training?
A. Not that I am aware of, sir.
Q. Thank you. How would you describe the RNLI’s current working relationship with His Majesty’s Coastguard?
A. Very strong, sir.
Q. Thank you. And we talked earlier about the 2010 agreement and the memorandum of understanding of 2020 and you helpfully explained that I think you were saying in the end both of them were under review and you were hoping for changes in May of this year. So far as the RNLI is concerned, is the aim of that exercise to bring everything up to date and in the process to address any loose ends, if I can put it that way, with reference to the small boats problem?
A. I think it’s fair to say the challenge around small boat rescue will certainly feature in the review of the documentation. Whether that results in specific things being put in a quite strategic document such as an MoU that remains to be seen. But certainly the events of the past six years will factor highly. As I’ve signposted already we need to be thinking about reviewing some of the performance standards that are contained within there. I think Covid reshaped some of those performance standards, the response times. I think we have a problem in the RNLI over speed and also the number of volunteers across the RNLI because ultimately people rescue people, so we need to have a sustainable model of delivery. So what I mean by that is normally our catchment area of volunteers would be within 10 minutes of a lifeboat station for a reason, but increasingly now I think we’re going to grow that catchment area and in so doing provide a more sustainable model of delivery. So we just need to understand that and work with the coastguard on that so that they have the latest planning information that we have.
Q. Yes. Then turning from them to Border Force. Again we have touched on this briefly earlier, but can you describe for us what you believe to be the current, the state of the current working relationship between Border Force and the RNLI?
A. I think the relationship between the RNLI and the UK Border Force is far better than it’s ever been. We must sort of bear in mind that we are separate declared facilities to the coastguard, but we must also recognise that the Border Force have done an outstanding job.
Q. So is it fair to say that the sort of incidents that we looked at earlier, the Ramsgate incident and those tensions which were obviously there, that those are a thing of the past?
A. I don’t think we could say categorically they would never happen again and I would always still encourage our launch authority to do right thing about the role that they have been empowered to do, but I would suggest it’s highly unlikely.
Q. Still no written agreement between you, is that right?
A. Written?
Q. Between the Border Force and the RNLI?
A. That’s correct, sir.
Q. Do you think there should be one to define responsibilities and roles?
A. I think responsibilities and roles fit within a declared status between the Border Force and His Majesty’s Coastguard and the RNLI and His Majesty’s Coastguard. And so I would suggest that’s more of a document that needs to be perhaps established between the coastguard and the Border Force. But certainly anything which supports interoperability we would be very keen to support and if that’s a loose framework agreement with the Border Force, I am sure we could explore that.
Q. We will come back to interoperability in a moment if we may. We talked earlier about the deficiencies as you saw them in the Border Force surface assets, the difficulties of resourcing, etc. I don’t want to go over that again, but can you bring us up to date on that? If we look at pages 22-23 {INQ010101/22-23} of your statement, for example, are there still changes and improvements in the areas you talk about there? Which is — so sorry, it’s pages 23-24 {INQ010101/23-24}, that’s entirely my fault. 56 to 58. Thank you. Are there still areas, you talk about there, where there is room for improvement now, today, March 25?
A. Yes, I think the area of concern that I would highlight as of today, sir, would be that as I’ve put in my last few sentences there —
Q. Yes?
A. — that increasingly now the masters of the CPV vessels if they arrive on scene and believe the conditions present too much risk to them, they will then call for RNLI support to undertake the rescue. So that risk is effectively transferred to the RNLI. So that would perhaps invite some attention around training or is the CPV the right type of asset. That’s not for me to say. It’s just to say that right now when our coxswains are tasked to small boats and we know Border Force are there, it means that we are going to a very tricky rescue.
Q. Yes. Are there any other points you wish to highlight as still requiring change or improvement in March 25?
A. No, I think I have captured it there in the evidence, sir. It’s really about ensuring if we believe that small boat crossing will continue in the foreseeable future, it’s to constantly challenge ourselves about do we have the right equipment, the right training, the right procedure in order to minimise the loss of life.
Q. And as I say you have pointed out these aspects in your statement. As far as you know, are discussions — have discussions taken place and are they ongoing on these sorts of issues with Border Force?
A. I am not aware of any discussions that might be happening. We did host Border Force at our last Mass Person in the Water event in October of last year, when again we were sharing our equipment, ideas and thinking including the trialling of new equipments. But I am not aware of anything of any activity that’s happening in the Border Force, nor necessarily would I be.
Q. No. Then interoperability you deal with in the previous paragraph 55, do you see there, on the left-hand screen, and you say there that the RNLI believe that gaps in interoperability do still exist especially in relation to multiagency response. And you go on to develop that with some examples; the transfer of casualties to Border Force assets, on scene command control/co-ordination, OSC, on-scene co-ordination or on-scene the co-ordinator or the individual: “The RNLI believe that OSC should not be delegated to the RNLI whose limited resource should be focused towards specialist rescue and lifesaving. This remains somewhat of an interoperability gap.” Again, is that something that you have raised with your stakeholder partners and tried to address?
A. Yes, I believe that we have had discussions with His Majesty’s Coastguard on this. It’s a very difficult one to solve and answer. But in the context, if I can just bring some colour to those words, if you have got a lifeboat crew with seven people and you arrive with mass persons in the water there will only be one person left inside the lifeboat who will be maintaining the radio and I think for that person, which is normally a float mechanic, to be expected to provide search planning and co-ordination when the coxswain and the crew will, quite rightly, want to be using their specialist skills to deliver lifesaving effect. So whereas in a lot of incidents such as a fishing boat that’s in distress we can provide a degree of on-scene co-ordination. I think in the context of small boats and multiple persons in the water, it’s not the appropriate use of the asset which begs the question what is.
Q. Yes. That was my next question.
A. Yes, and that’s something we want to try and work with the coastguard on. It could be a helicopter, it could be a Border Force vessel. But it’s just to put a marker to say we believe there’s a gap there and we stand ready to work with our SAR partners to try and fill it.
Q. Thank you very much. In this same paragraph, you specifically point out the difficulties in transfer of casualties, do you see that in the sentence six lines down: Examples of …”
A. (Nods).
Q. Can you just again develop that slightly to explain what the problems are?
A. Yes. So on the CTVs a modification has been done, so we have got an existing wind farm vessel. A metal boarding platform has been put on I believe it’s the port quarter and that is again to facilitate the cross-decking of casualties from a small boat on to the CTV. Unfortunately, in conditions where the sea state is above 1 metre, the CTV vessel is pitching quite considerably and when it’s alongside a rubber boat, which is very poorly manufactured — I use “manufactured” in the loosest sense of the meaning —
Q. Yes.
A. — should the metal platform come into contact with the small boat, that invariably will exacerbate the problem and present even more risk and invariably lead to persons in the water. I recall in 2022 we were being tasked to provide safety cover to the Border Force when the conditions were like this. I was slightly challenged by that originally because I didn’t perhaps understand the rescue need and whether it was an effective use of a lifeboat. But having seen some of the footage where it has gone wrong, we have changed our position completely and will encourage our crews it’s entirely appropriate that invariably we send an ILB or an ALB to support Border Force when the conditions are very challenging for them. But, again, it’s not made easier by this metal platform.
Q. No. So what are the changes? Apart from it looks like a change to the structure of the vessel, I mean what are the perhaps more realistic changes that could be made to improve this situation?
A. Again, sir, I don’t think it’s my place to comment on that. All I can comment on is that we did some understanding and some work from the RNLI perspective and out of that was born the SeaStairs, which is the rubber platform. So we have a rubber platform between a rubber boat, rubber platform and a glass fibre boat again to make that challenge of cross-decking safer and easier.
Q. As far as you know, has there been discussion about this with your stakeholder partners, the Coastguard and Border Force?
A. We have had informal discussions that I think the Border Force are acutely aware that this is an issue of concern for them and I think it’s actually gone as far as to now affect the risk appetite of the master to the vessel. They are aware of the constraint and so if there’s any element of doubt they will call for back up now. And what we have also seen is that the risk appetite of the organised crime groups has changed. So whereas before it used to be 0.5 metre sea state reasonably predictable in 2021 and early 2022; increasingly as the years go on the risk appetite of the organised crime groups have changed, their tactics have changed. They are now wading, the casualties are wading out to the boats —
Q. Yes.
A. — chest deep. So they are already cold and wet before they get in the boat. Larger numbers, as we talked about, and operating in — there’s no such thing as a green day any more I think the crews would say.
Q. Thank you. Just then some final questions, Mr Ling. We have talked about a lot of changes that the RNLI have made since the incident in November 21. But is there anything that we have missed out? Is there an area of change or, as you would see it, improvement since the incident that we haven’t yet touched on? Would you like to say something about that?
A. I’m not sure there is, sir. I’d probably say for us, in the RNLI, we are constantly seeking to adapt and evolve, we are looking to see the utility of in-shore lifeboats a lot more in small boat rescue activity. ILBs are quite restricted because they are weather restricted first of all, they are quite small, but they are quick and they’re effective and they can deploy LSA. We have just deployed to Walmer lifeboat station a new piece of equipment which is — we call a rescue board which can be towed out at speed by the lifeboat and then deployed in the centre of casualty in the water mass. So, again, it provides a floating platform to minimise the drowning risk and buy time for other assets to come and do the extraction. So, as I said, as a learning from the Aegean with this unprecedented rescue demand we need to constantly be challenging ourselves to adapt and evolve and make sure we are ahead of the game because the drowning risk remains high.
Q. Thank you very much and thank you for answering all my questions. Is there anything else you would like to say to the Inquiry today?
A. Just two things if I may, sir. First of all is you asked me about the Trent-class.
Q. Yes.
A. The reason why the Trent-class was in the table was because the Trent was operating at Ramsgate, but it’s now been swapped out by a Tamar. But we will supply counsel a chart which has the Trent included.
Q. Thank you very much.
A. But for the purpose of the transcripts now the Trent in its survivor capacity is 20, so that’s people within the wheelhouse, and 53 for external.
MR PHILLIPS: Thank you.
A. And then just finally, we just — I think we have covered today, sir, that the charity seeks to save lives at sea and we would wish to offer our condolences to the family and friends of those affected by this awful tragedy.
SIR ROSS CRANSTON: Well, Mr Ling, we are enormously grateful to you for the evidence, to your colleagues that are all behind you. You have covered an enormous amount of ground. It’s all extremely useful to us. Given some of your evidence earlier today, I really must pay tribute to your volunteers. They don’t deserve the sort of abuse that they have got and we should all be very grateful for what they do. But thank you very much indeed.
A. Thank you, sir.
SIR ROSS CRANSTON: We are not sitting tomorrow.
MR PHILLIPS: We are not.
SIR ROSS CRANSTON: But Thursday.
MR PHILLIPS: Yes, sir.
SIR ROSS CRANSTON: Okay, thanks very much indeed. (3.03 pm) (The Inquiry adjourned until 10 o’clock, on Thursday, 20 March 2025)
I N D E X
MR SIMON LING (affirmed) ………………………..1
Questions by MR PHILLIPS ……………………1