Wednesday, 12 March 2025 (10.00 am)
SIR ROSS CRANSTON: Yes. Good morning, everyone and good morning, Mr Bill. In a few moments, Rowena Moffatt of counsel will ask you some questions, but first of all, could you read the affirmation.
MR MICHAEL BILL (affirmed)
SIR ROSS CRANSTON: Yes, well, thank you very much.
Questions by MS MOFFATT
Q. Would you give your full name, please.
A. Full name is Michael Bill.
Q. Mr Bill, you made a witness statement dated 14 November 2024 which runs to 7 pages, that’s correct, isn’t it?
A. Yes.
Q. And you are employed by His Majesty’s Coastguard, which is part of the Maritime and Coastguard Agency.
A. Yes.
Q. And you have been so employed in various roles for the past 40 years, is that right?
A. I am in my 40th year now, yes.
Q. I am going to start with some questions to better understand your role in coastguard in November 2021, which is obviously the time that we are looking at. At that time, you were a divisional commander for coastguard division 2, that’s right, isn’t it?
A. Yes.
Q. And division 2, as I understand it, is from the Scottish border down the east coast of England, is that right?
A. It covers from — the geographical area is from the Scottish border all the way town the east coast, around the southeast corner as far as Southsea and West Sussex.
Q. I want to show you two organograms which have been provided to us by the MCA which show chains of command as at November 2021. So if I could put on screen, please, {INQ010205/1}. So this has the title “Operational overview”. You can see there “Division 2 Commander”, second from the left, reporting to the head of coastguard operations. Can you confirm this was your position in November 2021?
A. Yes.
Q. The box underneath refers to, I understand, division 2, which covers Humber and Dover MRCCs.
A. Correct.
Q. And so as I understand it, those are the two MRCCs which fall within your geographical region of division 2, is that right?
A. Yes, originally, as Division Commander we’d cover the coastal area, which was areas 5, 6, 7 and 8. I can’t remember the exact year, probably around 2019, we were also asked to look after the two MRCCs, or I think they were called CGOCs then, Coastguard Operation Centres.
Q. And you reported directly to the Head of Coastguard Operations who in turn reported to the Chief Coastguard. Is that how the chain of command worked?
A. Yes, I believe so, yes.
Q. And there are five other division commanders on this organogram. Did they cover different geographical regions, is that how it worked?
A. Yes, yes.
Q. Okay, thank you. I would like to replace that organogram with another one, the second one, which is {INQ010202/1}, this is called “Maritime operations – Dover MRCC”. You can see the top box says “Division 2 Commander”, that was you in November 2021?
A. Yes, correct.
Q. Two boxes below you, are “VTS”, which is the Vessel Traffic Service at Dover, and the MRCC Commander. Can you explain what the MRCC Commander role is?
A. The — I mean, there is one missing as well from there because we also had the — or I also line-managed the migrant or Small Boats Tactical Commander as well, at the time, it would have been in a similar line-up. But yes, so the Maritime Rescue Co-ordinations Commander, they had management overview of the team at Dover.
Q. Okay. So what you have said is essentially, the Commander role is the Small Boat Tactical Commander, George Papadopoulos and is there another commander then at Dover?
A. There was — well, there should have been. There was a maritime — an MRCC Commander, as that states there, but that person had left the agency just prior to the November 24th.
Q. Okay. And — so this doesn’t include maritime tactical commanders at the JRCC?
A. No, no. The JRCC is totally separate.
Q. Okay.
A. I had no — no — no sort of control or oversight of the JRCC.
Q. And who was ultimately responsible for the management of Dover MRCC?
A. For Dover, it would have been the Maritime Commander. I mean, it does say “SEO x2” now that I have looked at it properly, so the other one would have been George Papadopoulos.
Q. So it’s that person in the box on the right-hand side of the page, MRCC Commander, that would have been the person who was in charge of management?
A. Yes.
Q. Would it not have been you above that?
A. I –I was certainly above that position, yes, so — so I would have strategic oversight, shall we say.
Q. Okay. And did you also have a duty function in November 2021? Perhaps if you did, you could explain what the duty function was.
A. Okay, so normally, I wouldn’t be involved with — with the operational running of search and rescue incidents. But as — as a divisional commander, we were part of a rota or a roster where, I think, it is possibly one week in five, or one week in six, around that time, we would become the strategic commander for — for the coastguard nationally. So that role entailed having that strategic overview and, really, although the incidents were covered locally, say at Dover, they — they would be — there would be a network commander at the JRCC who would have that overall supervision over an SMC, whether the SMC be at Dover or remote. When I was the strategic commander, I could be contacted by a network commander, particularly if we had terminated an incident and we would have a discussion regarding that termination as to whether we had done sufficient before we terminated it and that conversation would also involve the SMC. So the three of us, between us, it would be determined if we had done sufficient before we actually closed that incident off.
Q. So the duty role could be — involve some operational involvement?
A. Yes.
Q. And does Duty Strategic Coastal Commander mean anything to you?
A. The —
Q. Was that your role?
A. Yes, yes. Well, it’s — I can’t remember whether it was merged at that time, but originally, because we were coastal commanders, we looked at — we took on a coastal duty role. So that meant that within our division, we had so many coastal areas, so my — as it said on that other slide, I had areas 5, 6, 7 and 8. Each of those areas had a Coastguard Operations Area Commander who I line managed and within each area, they had a duty system so that those coastal teams — so they looked after coastal teams. If a coastal team was involved in an incident, they could respond or get in touch with the duty coastal officer and obviously, that went up from operational tactical to strategic level. And I would have been the coastal strategic level. So where I undertook that role, I didn’t have any involvement in the maritime side. It was subsequently that the roles were merged. So when you became the strategic commander, you covered maritime and coast. But I can’t remember when it actually was when that happened.
Q. I see but the coastal is in opposition to maritime, is that how it worked? So you have a strategic maritime tactical —
A. Yes.
Q. Sorry, strategic maritime commander and a strategic —
A. Coastal, yes. We did have. It is a joint position now.
Q. The coastal is literal cliffs, beaches, is that how it works, as opposed to —
A. Yes, we have coastguard rescue teams. They do cliff rescue, mud rescue, water rescue. They could get tasked to an incident and yes, you know, it’s — the coast rescue side is the volunteer side, which is managed by the area commanders and a team of senior coastguard operations officers under them, up to six in each area.
Q. Okay. And where was your physical place of work in November 2021?
A. Where was I, sorry?
Q. Physically based, where were you?
A. I was based at Bridlington. I have been at Bridlington for a long time. My office was at Bridlington and when — when Dover became part of my operational guard, as such, I used to attempt to spend a week in a month ideally at Dover. I think in ’20 and ’21, we were a bit hampered by Covid so we maybe didn’t get there as often. But yes, I was at Bridlington all that week and the following week I came down to Dover.
Q. You have pre-empted my question. So you would spend some time physically at Dover —
A. Yes.
Q. — and how, otherwise, would you be in contact? How would you be kept up to date about what was happening in Dover?
A. With, we would have a divisional management meeting every month. So all — all my — the people I line managed, we would join in a meeting each month to discuss the operational business of the division. On a week — a weekly basis, I probably would be in touch of each of them on the phone for something or other. There wasn’t a scheduled meeting every week, but there was regular contact with the people I line managed.
Q. And did not being physically present in Dover present any challenges to your oversight and management there?
A. I don’t — I wouldn’t say so, no. You — you have got a regular briefing. Obviously, at the divisional management team meetings, we talked about staffing and things like that, casework, other issues that affected the station.
Q. In terms of your day-to-day role and functions, is it fair to say that the divisional commander role was a strategic and management role?
A. Yes.
Q. As opposed to getting involved in operational detail?
A. Correct, yes.
Q. And you wouldn’t be responding to individual incidents or —
A. No.
Q. — doing shift work, presumably?
A. No.
Q. And are there any circumstances in which you would get involved in operational detail?
A. Only when I was as a strategic commander.
Q. The duty strategic role?
A. Yes.
Q. Yes. And how often were you in that duty strategic role?
A. I — I think as — as I — I think it was one week in six or one week in five around that time.
Q. Would it be on an on-call basis when you were in your duty role?
A. Yes, you was on-call, yes.
Q. And would you be doing your — I don’t want to call it your day job, but the other divisional commander role at the same time as having the duty hat on?
A. Yes.
Q. Would it also be at nights that you would have the duty —
A. Yes, it wasn’t — it wasn’t a role that you got called regularly, to be honest. You know, you was on-call and there wasn’t that many opportunities when the network commander needed to involve the strategic commander. So sometimes it might be busy, but often it wasn’t busy. So often you didn’t get disturbed in the night.
Q. If we could just now put your statement on screen. So this is {INQ010097/1} wonderful let’s go to paragraph 8 of that, please, {INQ010097/3}. Paragraph 8, you set out who you directly line managed in November 2021. So fourth line down you say: “I would have been overseeing the work of 4 Coastal Area Commanders, a Counter Pollution and Salvage Officer and 5 Tactical Commanders … based at Humber and Dover Rescue Coordination Centres. These Commanders would have supervised those below the Commander level and the team leaders would supervise levels below that.” Then paragraph 9, just to look at that as well, you say: “As Divisional Commander I would not have been directly involved in Small Boat Incidents but I would have had an awareness of what was going on. I would have also been a point of contact, should the Tactical Commanders have required additional resource [or] advice, though they would not be expected to report to me on all matters.” So who were the four Coastal Area Commanders that you refer to in paragraph 8?
A. Do you want me to name them, or?
Q. No, just — I mean, are they based at Dover?
A. No. So we had a Coastal Area Commander for each of the areas. So at that time, as I say, I looked after areas 5, 6, 7 and 8. The area 5 commander would have been based at Hartlepool, the area 6 commander was co-located at Humber, the area 7 commander was based at Colchester, and the area 8 commander was at Dover.
Q. So there was one at Dover?
A. Yes.
Q. Yes. You also refer to five Tactical Commanders based at Humber and Dover. How many of these were at Dover?
A. Tactical Commander is possibly the wrong — I mean, they were — they were SEO level people. So at Dover — at Humber there was the one, which was the Maritime Rescue Co-ordination Centre Manager, as such, the — I think they were Controller, they were called, in them days. Dover had four there, so there was — there was the Rescue Co-ordination Centre Manager, there was the VTS Manager. I also looked after a COLO, Coastguard Operations Liaisons Officer, who reported to me at that stage. And then there was the Small Boats Tactical Commander; that’s four. The — well, the fifth one, possibly, was — would have been Matt, I would guess. Sorry —
Q. You said somebody was at Humber, so perhaps it is that person? You said five —
A. (Overspeaking) Sorry, yes, yes. There is four at Dover and one at Humber, sorry, yes. Sorry, apologies.
Q. You already told me you don’t supervise any Maritime Tactical Commanders based at the JRCC?
A. Yes.
Q. That’s separate. We have seen at paragraph 9 that you said you wouldn’t be directly involved with small boat incidents, but you would have been a point of contact if needed by the Tactical Commanders; and by Tactical Commanders, you have just said who they are, those four people at Dover.
A. Yes.
Q. You have said they weren’t expected to report to you on all matters. What kind of matters would they be expected to go to you about, in relation to small boat activity?
A. In relation to small boats, probably not — not too much, other than, you know, it would be issues regarding staffing and things like that, HR matters. I don’t — I can’t see that they would particularly call me regarding ongoing small boat incidents. There may be contact after from, you know, lessons learnt or something. But — but you know, they wouldn’t be calling me on day-to-day basis about small boat incidents.
Q. So if you had to say what the reasons would be for you getting directly involved in small boat incidents, it would be around staffing, lessons learned, it wouldn’t be in the operational detail —
A. No, no, it wouldn’t no.
Q. — we need to do — no?
A. No.
Q. Okay. Let’s go on to talk about your awareness of small boat incidents at Dover. We have already seen at paragraph 9 of your statement that you said you wouldn’t be directly involved in the small boat incidents, but you would have had an awareness of what was going on.
A. (Nods).
Q. When you say “an awareness”, what level of detail do you mean? Do you mean at a high level?
A. Yes. Every day we — we would get a — a daily operations report, which listed all the incidents that had happened nationally. If — if I wasn’t the StratCom and I was only looking after my division, I would focus on those in my maritime zones, look through the incidents. There was a separate document called a SOR, a Sensitive Operations Report, and that listed all the small boat incidents. I wouldn’t routinely go to that one. But if any of those incidents that I looked at, I thought: I need to look a bit deeper in that, I could then refer to the BOSS system which we have, which is a browser version of the ViSION incident database that the ops room use and I could — I could trawl through that incident for whatever it was I was looking at. Additionally, on a — on a — I think it was on a daily basis, well, additionally, if we had small boat operations going on, I would be aware because I regularly dialled into the Operational Deveran weather forecast. So I knew when we were getting red days, green days, etc, when we were likely to be busy. If the forecast was we were likely to be busy, normally, I would look at the tracker. I would — I would open the tracker in the morning and look through the incident, see how busy we were, how many — how many incidents we have actually had and things like that.
Q. So the tracker would be your one-page document way of keeping on top —
A. Yes, it was a summary on a page really, yes.
Q. You were obviously aware of the large increase in small boat crossings in 2021 and in particular, in November 2021. Was this awareness from having been at Dover yourself, or speaking to colleagues there?
A. It, it was both really. I — I had been at Dover when there were — they were particularly busy and obviously, you know, the feedback from the teams, you know, I would be aware of how busy they were and how it increased.
Q. And linked to the increase in small boat crossings, you were aware of problems around staff shortages at Dover —
A. Yes.
Q. — in 2021. Who, within coastguard, was responsible for dealing with the staff shortage at Dover?
A. Well, the staffing — obviously, the MRCC Manager was responsible for staffing of the station. But I would be offering support there to try and — it was — you know, it was highlighted we had issues with staffing. So I –I would be offering support there, trying to push through, with my colleagues, recruitment and looking if we could increase staffing, etc. So I am guessing that I would be the link with seniors level within the organisation to try and get extra staffing at Dover or to get recruitment campaigns to fill vacancies.
Q. So you were involved in managing the problem, essentially?
A. Yes.
Q. Being the link, as you said, between senior levels and the staff at Dover?
A. Yes, and working with our HR resourcing team.
Q. And did anyone at Dover, the staff there, directly raise concerns with you?
A. It was — it was often raised. So — the MRCC Manager at the time would obviously raise concerns. I think when — when we first took on the station, or I first started to look after it, there was vacancies already there. And the MRCC Manager was working hard to try and fill those vacancies through recruitment campaigns.
Q. I would like to now look at an email that you sent in the summer of 2021. The date is 17 August and the number is {INQ003322/1}. So the bit we want is the bottom half of the page which starts “Good …” There we go. So you will see — you can see that, presumably. It is sent on 17 August 2021 —
A. Yes.
Q. — in the morning and you sent it to the Chief Coastguard, Peter Mizen, as then was. And it’s a long email. I am not going to read it all out, but I want to look at certain parts of it. So this is an email where you raise, with Chief Coastguard, certain concerns about HM Coastguard’s response to small boat activity and list a number of recommendations. Do you recall this email, or do you recall sending it?
A. Yes.
Q. Yes, so it’s clear from the first line: “Below may be worthy of further discussion during our planned call today.” That this was sent in advance of a call. Do you recall if that telephone call took place?
A. Sorry, “below may be worthy”, I am guessing we will have had a conversation, yes. To be honest, I can’t recall the conversation.
Q. You can’t now recall?
A. Yes.
Q. Okay. So, let’s look at the email then. The email summarises some concerns raised internally within HM Coastguard about the impact of small boat crossings on HM Coastguard, in particular, by two reviews in summer 2021. You provide a summary, from those reports, of what you consider to be the key areas of concern relating to small boat search and rescue at Dover. So we can see there, towards the bottom of page 1, you say: “The amalgamated list of recommendations is captured at the bottom of the email but I’ve highlighted in bold below …”
A. I can’t see that, sorry.
Q. So the — there we go.
A. Sorry, sorry.
Q. The cursor has just come, yes. So: “The amalgamated list of recommendations is captured at the bottom of the email …” We will look at that in a minute: “… but I’ve have highlighted in bold below what I feel are the key areas of concern …”
A. Yes.
Q. “… and cover several of those recommendations.” So I want to just look at those key areas of concern, so essentially the bold bits in the email. The first one highlighted in bold is the one just directly below, which says: “Lack of situational awareness and challenges of the remote SMC.” So what I understand this to refer to is a situation where remote cover, so the network flexing provided by HM Coastguard, and an SMC is not physically present in the operations room. Could you explain the concern around not having the SMC in the operations room?
A. Yes, I mean, the SMC — part of his role was to maintain oversight of all the incidents and obviously give guidance as to — as to how that was progressed, how they prosecuted those incidents. As it — as we started to get large numbers of incidents, that — that became a massive challenge, to be fair, for remote SMC. They — they would struggle to maintain oversight of what could be 20 or 30 open incidents which were all classed in the distress phase. So it was a challenge. The only problem — as we didn’t have any other option, we only had three SMCs at Dover at the time, staffing was — we — we had poor — shall we say, poor retention of staff there. So experience and competent weren’t the best. So it was difficult to push people through for SMC; there wasn’t many people that had the experience, that were ready to go at that stage. Although those that were, were being progressed, but that — obviously, we had to rely on a remote SMC. There was — there has to be an SMC.
Q. And what was the particular problem around it? Was it that you would miss certain updates verbally that you might get in the operations room that you wouldn’t get when you were remote in, let’s say, Humber or JRCC?
A. Yes, I think, as well, when you are the SMC in an ops room, you have got the — you overhear things. You overhear parts of conversations that might not get recorded in things. You see colleagues in the ops room, whether they are struggling; you can see it physically. Whereas, when you are remote, you are divorced from that. I mean, we added other tools subsequently, such as iPads and hubs and things like that, so that vision was improved. But at this stage, we didn’t have that and that was something the remote SMC missed.
Q. Was it — in August 2021, when this email was sent, was it fair to say that there was a problem that had been recognised in HM Coastguard’s system of network flexing or remote cover?
A. Well, it appeared — it certainly appeared to be a problem from these that did it. I think the background to this incident was from an SMC at Humber who had taken — who had done the remote SMC and then he produced an email identifying the challenges. And I think on the day he was there, it got to the stage where he felt he had lost control and had to hand the SMC over to somebody else. So it was definitely identified as a challenge.
Q. Let’s move on to page 2 {INQ003322/2}, bottom of page 2, right at the bottom, the next heading is “Staff at capacity for long periods.” We have already talked about staff problems at Dover. I understand this to refer to staff welfare concerns at Dover. And you see there, right at the bottom of the page, in italics, it said: “There was genuine concern for the welfare of those officers involved in the [search and rescue] response, with no adequate time available for rest, comfort or meal breaks.” If people weren’t able to have any of their allocated breaks, it sounds as if staff at Dover were overwhelmed in summer 2021. Is that a fair characterisation?
A. There was — there were certainly challenging days when they worked non-stop, yes.
Q. And what did you consider to be the particular risks around staff being in this situation?
A. Well, obviously, there would have been — we could lose people for stress-related absence, one thing or another. The — often, the — the — such as the MRCC Commander, would try to support by — I know, bringing pizzas and things like that and try and — you know, they would eat at the desk and things like that, which weren’t an ideal break, but they tried to make it a bit easier. But, yes, obviously the biggest concern was would be with would he lose some more officers because of overworking, stress.
Q. Impacting on performance also?
A. Pardon?
Q. Could it impact on their performance also?
A. It — it could. But I mean, operational performance should have been being monitored anyway.
Q. Let’s move on then, page 3 {INQ003322/3} at the bottom, or towards the bottom half, you will see the next bolded heading “No single version of the truth …” This refers to numerous small boat, so-called, trackers —
A. Yes.
Q. — those documents which, on one page, would summarise all the small boat activity. So in terms of the multiple small boat trackers, this was coastguard, Border Force and the French?
A. Yes.
Q. Can you explain what you sought to convey in this email by the words “No single version of the truth”?
A. I think — I think the problem was that at this stage, ideally, we needed a joint tracker so that everybody got the same information at the same time. So at this stage, there was the French tracker, which sometimes we got early, sometimes we got late, and that identified all the incidents that had started in France and were heading towards the UK waters. Border Force had their own tracker, of a fashion, which was the Op Deveran live version. They would enter detail in there, which ideally, would be shared with the COLO, which was the Coastguard Operations Liaisons Officer, who was also based in the JCR. They had desks more or less alongside each other, they would speak to one another and share information. But they were duplicating information on two separate trackers. So it — it was — it was open to mistakes. So — so yes, we had three trackers, which sometimes would show slightly different things, rather than having one which — we could have a joint checker, which everybody shared, which — which we worked towards and eventually, we overcame some of the challenges with different IT systems with the Home Office and Coastguard and managed to get a joint SharePoint document that we could all use.
Q. We will come on to that. Let’s just finish on the email then. So further down the page, you have got the next bolded heading “High level [of] migrant activity … not [being] restricted to Red days.” But also taking place on amber days. So essentially, this was referring to the frequency of days of which small boat activity was taking place, increasing?
A. Yes.
Q. Then finally, page 4 {INQ003322/4}, there is a heading right at the top “Major incident or not”, where you say: “These high intensity days meet our definition of a Major incident however we are not declaring it as such. To do so would advertise to the wider world (perhaps not preferred by Home Office) but would also inform our partner agencies that we are stretched at Dover and may not be able to support any requests coming from them.” Can you explain why you understood the definition of “major incident” to be met?
A. One of the criteria for a major incident was — was multiple incidents happening at the same time. That’s not the exact wording, but it basically means that. And which on — on the high intensity day, a red day, we probably met that criteria.
Q. And despite that, coastguard didn’t declare a major incident at the time, as I understand it?
A. No.
Q. Do you know why?
A. Some of it was possibly political.
Q. Political within HM Coastguard, or …?
A. I think, obviously, it was high profile with the government and migrant crossings, etc, and they didn’t probably want that in the news. Should we have declared a major incident, it was bound to hit the news and things like that. So that’s what I mean by political.
Q. And you suggest there that the Home Office may not want coastguard to advertise that it was dealing with a major incident to the wider world. Is that also what you mean, when you —
A. Yes, that is what I mean, really.
Q. And whose decision was it to declare a major incident?
A. It could be declared by various grades. The SMC could declare a major incident. Anybody in that operational chain of those ongoing incidents, or a network commander could have done and even above the network commander.
Q. So you could have done as well?
A. If I was duty — if I was involved in the operation, yes.
Q. Okay. You also say that it would inform coastguard’s partner agencies that you were stretched, or HM Coastguard was stretched. What are the partner agencies?
A. Well, within an LRF — we engage with an LRF and that’s all the other emergency services, the local authority, etc. So when there is a major incident declared, they would be informed of that major incident. Now, the other challenge we would have by declaring a major incident is that every one of those organisations would be dialling in to try and find out more information. The ops room were overwhelmed; they didn’t need all this additional feeding the beast. So that was another reason why we avoided declaring a major incident because it wasn’t — they couldn’t offer us anything to support; they didn’t have vessels, they didn’t have aircraft. All they could offer us was support on land and on land wasn’t the issue. It was — it was the actual co-ordination at sea. So in some way, it was pointless telling them and getting them involved; it would only be for information, they couldn’t really offer us anything. The other side of it would be if they subsequently declared a major incident themselves, for something on land, they would know that we were already stretched and couldn’t support that major incident.
Q. And would partner agencies then — would that have included RNLI and Border Force —
A. No, no. No, they are not part of the LRF.
Q. LRF, could you just define what that is?
A. Local Resilience Forum.
Q. Thank you. I think I know the answer to this question already because I think you told me you can’t remember the call. But presumably you don’t, or do you remember whether you discussed major incident with the chief coastguard on this call?
A. No, I don’t, to be honest.
Q. Was any major incident planning conducted by HM Coastguard to your knowledge? So risk assessments, planning.
A. Well, major incident planning was covered within standard training, within various training courses about the declaration of major incident.
Q. I want to now look at the rest of the email; it is on the page already. So, page 4 you provide what you say is the amalgamated list of recommendations, nine of them, which you say were taken from these two reports that you have had regard to, in order to brief the chief coastguard, essentially.
A. Yes.
Q. So on page 4, you can see under the line, which says: “The list of recommendations are generally mirrored in both reports …” And then you provide the list and there are nine points. The first three related to ensuring sufficient resourcing and preparation for amber or red days. And you have referred to various options that you had mooted in the previous section. The fourth then related to ensuring adequate Standard Operating Procedures and training, which you said was in development at the time; is that right?
A. Yes.
Q. The fifth was about lesson learning, which you said had been started by reference to the reports that had informed the recommendations. The sixth referred to welfare support for staff and you said there were various options you set out earlier in the email. Then on to page 5 {INQ003322/5}, seventh related to the use of broadcast action in relation to small boats. The eighth related of importance to early access to the French tracker; you have already told us that sometimes it would be late. And you say it would hopefully be resolved at the next meeting with French colleagues. Ninth related to Border Force having access to coastguard’s tracker; you have already talked about. And the tenth related to HM Coastguard’s policy of designating all small boat incidents as distress and whether Standard Operating Procedures should be amended. Can you recall if any decisions were taken as a result of these recommendations being put forward?
A. No. Obviously, some were progressed, but I — I can’t remember. I can’t — I can’t remember any — any decisions coming out of the subsequent conversation I had with the Chief Coastguard.
Q. So there was no type of formal action plan put in place to implement each of these recommendations?
A. No.
Q. So again, you depended don’t know whether each of them was considered and there was a decision made, whether or not to progress?
A. No, and I certainly didn’t get a written response.
Q. The recommendations didn’t include the coastguard declare a major incident, despite you having said that the definition was met. Why was that?
A. I think partly because of the reasons that I mentioned, that by declaring a major incident, it wouldn’t really help us.
Q. Okay. And do you consider that any of the problems you had identified in August 2021 were resolved by November 2021?
A. We had the — we had the combined tracker by that stage. I think it was around about 22 November, where everybody had access to a combined tracker. The French migrant tracker, that was raised at a meeting which I don’t think is in the pack, but I — I’ve got — certainly got copies of that meeting, which was the August meeting we had with the French. And it’s noted in there that we raised the matter about the — again, early notification of the French tracker and the challenges we have when it’s delayed. So — so that that was being resolved.
Q. Were you aware that on the night there was a delay to the French tracker being sent?
A. Yes, yes.
Q. So being raised, but not resolved, by November 2021?
A. Yes, it’s it had been — it probably had been raised a few times, but I think obviously, the French would have a — I don’t know what — how they shared their information, whether all their teams were aware of the difficulties we had by receiving that late. So I — I can’t say how that was distributed from our joint meeting onto their teams, as such.
Q. I want to, now, take this one down and if we could perhaps put another one up, it is {INQ003322/1} an email you sent later on the same day to Assistant Chief Coastguard, copying Coastguard and the Division 4 Commander. If we could just go to the bottom half of the page, please. Yes, there we go. Oh, hang on. So sorry {INQ003327/1}. So — yes, there we go. This contains your proposed text to seek qualified operational staff to come to Dover for a period of duty. And the first paragraph refers to Dover being challenged by high small boat activity and then says: “Dover at this time is also low on staff numbers, experience and competence and although best efforts are being made to improve this situation [you refer to the recruitment drive] the position will not change sufficiently before the end of the summer/autumn period when migrant activity is expected to remain high.” And the email goes on to request staff elsewhere in coastguard’s network to undertake a period of duty in Dover. So that email was sent in the evening of the same day that you had written the email to the Chief Coastguard and had the call, presumably, with them. Do you think that might have been an action point taken as a result of the email and the call?
A. Well, possibly, yes. Yes.
Q. And were you aware of whether any coastguard staff came to Dover as a result of this request?
A. Yes, we — I mean, we tried various things to try and get staff to Dover which — you know, we offered overtime. Overtime was offered nationally, so that they could take a desk remotely and support the team. Not necessarily the remote SMC, but you know a remote officer in a desk supporting that team, taking a function from Dover, such as channel 16. We also put out a regular request, if anybody wanted to come down there on detached duty. And an expression of interest was — did eventually go out, asking for people to come there on detached duty for periods. The more local teams, such as the JRCC and Humber, which regularly got involved supporting Dover, we tried to encourage those staff to actually come physically to Dover for a period and work from there. Obviously, I was co-located at Humber, so I had a few words with the team leaders there, but couldn’t, ultimately, persuade them to go down. We did get some from the JRCC which actually came and spent time at watches there. There was also — I recall staff came from Stornaway, for week at a time, to actually assist the watch and understand the issues. Once the expression of interest had gone out, we did — eventually, I managed to get two staff that came there on long-term detached duty. So I had one from Aberdeen, who was obviously a qualified officer, which helped a team which was lacking in competence, and she remained there for, I think, it was up to two years and subsequently, became a team one of the team leaders there. And the other one came from Humber and I think she stayed for about six weeks — sorry, six months before she found alternate employment.
Q. So did it ease some of the problems?
A. It obviously helped by having those people there and certainly, because we had experienced staff — other experienced staff there on station, they could assist with on-station training, developing the new team. I –I also at the time, it was partly because of Covid, but we mentioned the team there that joined, the five MOOs that joined in March/April, the intake was actually seven, but two decided it wasn’t for them very soon after joining. So the five we had left in March/April, we wanted to try and up-skill them by the summer so they could play an active part within the watch. Now, the training centre had some of its own issues in capacity to deliver all these MOO courses because it wasn’t only Dover that wanted new MOOs, the JRCC at the time, they also had quite large vacancies. So there was all sorts of recruitment campaigns going on. So we were fighting in some ways to get training capacity. So — and I think also around there, we had the restrictions with Covid and travel and one thing and another. So I did manage, at that stage, to speak to the training centre and they allowed me — because I had the commitment from two of the team leaders at Humber, they were prepared to do the week’s communication training over Teams to these five new staff, who could in separate training room at Dover. And they went through the comms module, so they were then qualified and had some competence that they could support what was going to be a busy summer.
Q. And the email says, last sentence, that you urgently needed offers of support for August and early September and you said — it says that you also would consider offers until the end of October. Do you know why the request was limited to the August-October period?
A. I –I think we — we tended to do it on a quarterly basis. It did carry on after that October, we continued to ask for support.
Q. It did. Let me, now, turn to the events of 24 November 2021. Were you — you were working on the day shift that day, that’s right, isn’t it, in Humber, presumably, or were you in Dover that day?
A. Yes, I would have probably — I — although my hours were 9 to 5, I didn’t — I obviously, like a lot of others, we did more hours than we were supposed to. But I would probably get into the office about 8 o’clock in the morning and then carry on until probably gone 5, 6 o’clock-ish. But, yes, I was, I was at Humber all that week. One of the reasons for being at Humber that week was that we had an operational standards and performance review that was ongoing for the Humber team. So we had a standards team there, at Humber, inspecting in the watch over that period. So I obviously wanted to be on site, should they raise any issues with the Humber team.
Q. And did you have your Duty Strategic Coastal Commander hat on that day, do you know?
A. No, I wasn’t duty.
Q. No. And would your role and functions have been the same as any other day, at the start of the shift on 24th?
A. Generally, yes. Often, it was governed by whether we received on email, but there would be other functions that we would be getting on with. So obviously, I had planned to be involved with the OSPR team that day.
Q. Okay. So I want to ask you some questions about the tracker that we’ve already talked about.
A. Yes.
Q. Let’s just put an example of it on screen, so {INQ006835/1}, please. This is the iteration of the tracker — it will come up shortly — at 08:30 in the morning. We will look at your entry on this shortly, but this is just to familiarise ourselves with it. So if we just scroll — there we go. So this is familiar to you, presumably?
A. The tracker is, yes.
Q. Yes. And so you can see, obviously, on the left-hand side, we see the phonetic alphabet reference from coastguard, and then the columns on the top, refer to the various bits of information about each incident. So the initial report source, the various references, French, HM Coastguard, Border Force, mobile phone numbers from the small boats, position information, whether it’s in French or UK waters, description of the vessel, how many people on board, whether there’s been an asset tasked and which asset it is, a column for notes and a column for outcome. Would it have been something that, in your job role you would have been — you said you would look at it, to keep an overview, but would you be routinely updating it?
A. No, no. When — well, I will let you come on to it. No, I wouldn’t. No.
Q. So, do you remember ever updating the tracker, either before or after November 2021?
A. I honestly don’t. The only thing that I do remember doing is — this tracker came out on a monthly basis, so it was a spreadsheet over a month.
Q. Yes.
A. And for each of those tabs, the sheets at the bottom, you would have a day whenever we had activity. Now, often those sheets would get out of order and whether it’s some disorder I’ve got, but I didn’t like to see the 14th, then the 18th, then the 15th and 16th. So I would rearrange those sheets back into chronological order. It could be a problem I’ve got.
Q. I am sure that’s understandable for lots of us in this room.
A. Yes, but that would really be the only entry I would make. You know, it was open to me; it wasn’t protected. It was a document I could —
Q. You could amend if you needed to —
A. Well.
Q. One of the Maritime Tactical Commanders who has given evidence to the Inquiry said that he would only update it in extremis. Is that something that might apply to you as well?
A. Yes, really. Yes, because it was done mainly by the Operational Liaison Officer who worked with the JCR and the staff actually based in the ops room at Dover.
Q. Well, let’s look at the index of each iteration of the tracker. You have already — you talked about this in your statement, but this is {INQ007058/1}. So if we could just put that on screen. And essentially, this is the index of SharePoint version, so every time the tracker was amended or changed —
A. Yes.
Q. And we will see it in a minute, I can just take you through it. There we go. So we see, then, under column B the SharePoint version number, so that’s the number of each version of the spreadsheet. Column C, change date, so it also has a time there. And then a column E, change author, the identity of the person who made it.
A. Yes.
Q. If we look at row 64, so scrolling down to 08:35 in the morning — for some reason, this is the wrong version of the tracker. Okay. Well, we should be able to see your name there. You might have to just trust me on that. But it’s been, unfortunately, redacted, but your name should be there.
A. Okay.
Q. I don’t know if we can get the right version up, but if not, you might just have to trust me on that.
A. Yes, I did see it previously, yes.
Q. Yes, and in your statement you say that you have no independent recollection of having made this amendment?
A. No.
Q. But you accept it’s possible that you did?
A. Well, the IT would suggest that I did do it, yes, that I made an entry of an M number, yes.
Q. Is there any other explanation that you can think of, other than making the amendment, for why your name would be on the index of versions?
A. No, I have gone back through my email of that day because I have still got some Outlook email from around that time — not to say something couldn’t have been deleted, but I am surprised that if there was something to do with an M number reference in that email why I would have deleted that and left other email there. But when I look at my email, I think at 08 — I think it was about 08:15 or something in the morning, I was involved with responding to one of the network commanders regarding staffing policy — well, not staffing, annual leave policy, for the maritime operations. I think slightly, after 08:30, I had sent an email to estates regarding EV charge —
Q. Are you going on to the source of where you think it might have come from? Is that what you’re —
A. Yes, I was looking through my email. There is nothing there that relates to where I could have got this information from.
Q. Let’s come on to that. The question I was asking or I was trying to get at is: can you think of any other explanation, apart from the one that IT gives us, as to why your name would be against it? Could someone have logged on to your account and added it?
A. I wouldn’t have thought so, no.
Q. No, it seems unlikely.
A. Yes.
Q. So it probably was you. Can we just put the tracker on screen, so this is {INQ006835/1}, the 08:30 version. We will come on to what you were talking about then about, you know, trying to work out how it could have happened. I appreciate it happened a long time ago and you are not going to have a clear memory.
A. Yes.
Q. You are unlikely to. So the amendment that the index document identifies you as making, as you have said in your witness statement, is the addition of the Border Force reference, or M number, of M958 to the row for Incident Lima, so the cursor is going to be there now. Yes, there we go. Do you recall having any operational involvement in Incident Lima?
A. No, I didn’t. I didn’t have any operational involvement.
Q. So, in terms of the source of the amendment, in your statement — I think you were coming on to this now — you said that it’s possible that you were provided the M number by email, but you can’t find any emails to suggest that?
A. No, I — I mean, the only other source would possibly have been a telephone call. Now, I wouldn’t have been in communications with the ops room at that time of the morning and knowing they were busy, I wouldn’t be adding to their grief. But the COLO, the Coastguard Operations Liaison Officer, he would have started about 7 o’clock that morning. So I could have had a conversation with the Coastguard Operational Liaisons Officer, but it would seem illogical as to why I would input that. If he’s given me that number, that figure, it would seem illogical as to why I would input it, when he is sat at a desk with his tracker in front of him all the time and it is quite easy for him to input that. So it just doesn’t — doesn’t add up to me.
Q. Just going back to the emails. If you can’t find any, is it fair to say that there probably weren’t any?
A. Yes.
Q. And another member of HM Coastguard staff who was providing remote support from the JRCC that night and also updating the tracker, has said that he used the ViSION logs in order to update the tracker.
A. Yes.
Q. He was, essentially, operationally involved in Dover, so different to you. Would you have also been scouring the ViSION logs to update the tracker? Is that something you could have done?
A. I could do, yes. I wouldn’t necessarily have — from what I can see at that time of the morning, for Incident Lima, it was obviously still ongoing. I wouldn’t necessarily have gone into BOSS and have a look at it. I have subsequently looked at it and there is no reference to that number in that incident.
Q. Exactly. I won’t even bring that up now because you recognise that. Yes, in the Incident Lima log, there is no M958; it doesn’t appear.
A. No mention there.
Q. So it can’t have been from that?
A. No.
Q. Are you aware now that M958 was not, in fact, Incident Lima? Is that — are you aware of that?
A. I am not sure whether I’ve seen — I might have seen — I am not sure that I have seen the Border Force Op Deveran which allocated it to another incident. Was it Golf or something like that?
Q. So Incident Lima was the first small boat picked up by the Valiant that night, which had been given the M number of M957, so this entry on the tracker was actually an error. Do you have any idea how that could have come about, how an error — how you could have entered an error on the tracker?
A. No.
Q. Last question on the coastguard tracker. You have said that Border Force gained live access to the tracker shortly before 23 November.
A. Yes.
Q. At that time, had you heard anything about Border Force being supposed to enter the M numbers themselves and taking that away from HM Coastguard?
A. No.
Q. No. And let’s, finally then, look at the Border Force tracker or log, their separate one that they were still maintaining on 23 and 24 November, even though they had just gained live access. This is called the Operation Deveran live update and you talk about it in your statement. So if we could bring statement back up please. So this is {INQ010097/1} page 6 {INQ010097/6}. There we go. You see the heading “Operation Deveran Live Update”. And if we look at paragraph 19, what you say there is that HM Coastguard used the Border Force tracker to ensure it matches the information on the coastguard tracker. So I think what you are saying there is that it’s referring to this no single version of the truth, essentially, that you had these two trackers and you had used them to make sure that the information tallied.
A. (Nods).
Q. Would you be doing that?
A. No, I mean — I think as I mentioned previously, in the joint control room there was a Border Force officer that was allocated with — with updating that — that — their document. And almost alongside them, was our Coastguard Operations Liaison Officer, who would have our tracker there. And between them, they — they would share information and update each tracker.
Q. And that would be in Dover?
A. That’s in Dover.
Q. With the COLO, and —
A. Yes.
Q. Yes, and in paragraph 21, you say you don’t recall there being any policies or procedures in place regarding the Border Force tracker, correct?
A. Yes.
Q. So how do coastguard know how to use the Border Force tracker, in the absence of any policies or procedures? Did practice just — you just referred to this practice of the COLO sitting there checking; is that just something that evolved over time?
A. Yes, I think — I think it did because, I mean, that was their role to liaise with one another, to try and get, you know, a joint understanding of what was happening. So yes, it was a key function the COLO role.
Q. Finally, it’s correct that you remain in the role of Divisional Commander is that right?
A. I do, yes.
Q. Are you still involved with the management of Dover?
A. Yes, we have had subsequent — we have had some changes to the division. So I think it is just over two years ago now, division 2, it was apparently — it was obviously quite big, so division 2 was sort of changed. So I no longer have any operational involvement with Humber, although I am based there and I now look after Dover plus two coastal areas. So it’s — it’s reduced quite a lot from what it was.
Q. So it’s reduced and also increased — focused in on Dover even more, possibly?
A. Yes.
Q. Are you aware, then, of changes at Dover as a result of lessons learned from the events of the 23rd?
A. There’s been lots of changes. The situation now is totally different from what it was then. We have had, obviously, a great uplift in staff, we have separated the VTS function, which was a massive draw on SAR ops. The station has been revamped to add more desks. We have had continual recruitment campaigns, so now, although we still aren’t fully staffed, we are carrying six vacancies at the moment. But the staffing that is there, there is 38 operational staff and a separate VTS function. And so we are regularly five or six on watch. We have still got the challenge with competence because when you look at it, we have probably only got three staff that have been there longer than 2021. We have had quite a lot of turnover there. And one of the challenges of that is that other government agencies can offer a lot more money. Some have left because it’s obviously a stressful role. I don’t get to see all the exit interviews. So I am not sure what they put on the exit interviews, but most of the people I speak to before they leave, it is usually financial reasons. But now, it’s — it’s massively changed and to support that, we have a greater amount of maritime assets out there. So Border Force have now got five vessels rather than one, that we — maybe one or two that we had then. Air surveillance is more or less 24 hours, so we have a better overview. The French have upped their game and they have probably got five or six vessels now that shadow the small boats until they get to UK waters. So it’s a totally different operation.
MS MOFFATT: Thank you, Mr Bill. Those were all my questions for you. Sir, I don’t know if you have any? Questions by THE INQUIRY
SIR ROSS CRANSTON: Mr Bill, just to take you back to that email of the 17th, where you set out in detail your recommendations. You told Ms Moffatt that you didn’t get a reply in writing. Did you have a reply in person?
A. I — I can’t recall, to be fair.
SIR ROSS CRANSTON: Would you normally expect to get at least an acknowledgement to that sort of report that you put in?
A. We would have probably — we would have had a conversation, it may well come in the conversation, but I certainly — I wouldn’t necessarily expect a written response.
SIR ROSS CRANSTON: You wouldn’t?
A. No. No, it would be nice if I did, but I wouldn’t — I wouldn’t always expect that.
SIR ROSS CRANSTON: Have you prepared reports like that in the past or after?
A. I think I probably have, yes.
SIR ROSS CRANSTON: And did you get responses to them?
A. From sometimes, yes.
SIR ROSS CRANSTON: Well, thanks very much. Thanks very much, Mr Bill. Very helpful. Thanks for statement, also the evidence this morning. I think we will have a 10-minute break and then we will have Mr Barnett. Right. (11.00 am) (A short break) (11.10 am)
SIR ROSS CRANSTON: Yes, good morning, Mr Barnett.
A. Good morning.
SIR ROSS CRANSTON: Could you please read the affirmation.
MR CHRISTOPHER THOMAS BARNETT (affirmed)
SIR ROSS CRANSTON: Yes, thank you. Ms Moffatt.
Questions by MS MOFFATT
MS MOFFATT: Could you give the Inquiry your full name, please.
A. Christopher Thomas Barnett.
Q. Mr Barnett, you made a witness statement dated 18 November 2024, which runs to 21 pages, correct?
A. That’s correct.
Q. And in November 2021 you were employed by His Majesty’s Coastguard?
A. Indeed.
Q. And you remain so employed?
A. I do.
Q. You joined HM Coastguard in 2017 as a Maritime Operations Officer, or M-O-O, or MOO?
A. MOO, yes.
Q. And you were promoted to Senior Maritime Operations Officer in 2019?
A. That’s correct.
Q. And to a Search and Rescue Mission Co-ordinator, or SMC, in 2020?
A. Yes.
Q. And then later in the same year, promoted to Team Leader?
A. That’s correct.
Q. And in November 2021, you were an SMC and Team Leader at the JRCC, which is coastguard’s central operations centre in Fareham, Hampshire, correct?
A. That is.
Q. Your role now is a Maritime Tactical Commander, a role to which you were promoted in August 2023?
A. Correct.
Q. Still based at the JRCC?
A. Indeed.
Q. In terms of the role of SMC, this is an operational role, as I understand it?
A. Yes, that is.
Q. And you are in charge of an incident, or incidents, as an SMC?
A. Yes, it is a qualification that you — you hold and are in charge of it, yes.
Q. And you are managing a team of MOOs?
A. So operationally, in — in — through that incident, yes. We are, yes.
Q. And in terms of the role of Team Leader, this is a management role?
A. Yes, so pastoral care, welfare, staffing, timetabling, and also doing the SMC part.
Q. So that’s additional to being —
A. Additional — yes, additionally.
Q. And you have told us that you were an SMC and Team Leader at the JRCC. This was also where MRCC Solent was based?
A. Yes, so Solent coastguard is based at the JRCC.
Q. And that’s HM Coastguard’s MRCC for the Solent area?
A. Essentially, yes.
Q. And did you have functions within MRCC Solent that were additional to your function as an SMC and Team Leader at the JRCC?
A. On that evening, or in general?
Q. In general.
A. In general, yes. We look after long-range search and rescue. There are a number of coastguard functions that are rotated and shared between MRCCs.
Q. And on the evening in question, I believe you were also — were you also involved in Solent on that evening?
A. Yes. So myself and another colleague, another SMC, we had a full part, SMC for Dover and as well as Falmouth, as well.
Q. Yes.
A. As well as looking after some staffing needs for them as well.
Q. We will come on to that in due course. But before we do so, I want to ask you about your experience of small boat search and rescue by November 2021 and any training you had had about that. So if we could put up your witness statement, please. So this is {INQ010140/2} there we go, wonderful. Paragraph 6, please. First line of paragraph 6, you say that you got — that you can’t recall any formal training specific to small boats. Does that remain your recollection?
A. It does, yes.
Q. And just to push that further, you don’t recall attending any presentations at the JRCC in August and September of 2021?
A. There was a presentation that’s included in the witness pack, but I believe, based on the dates, I was not in work at that time.
Q. And four lines down, still on paragraph 6, top of the next page {INQ010140/3}, you have said that you can recall there was regular guidance updated and circulated. Were you involved in updating any of the guidance that you refer to?
A. I wasn’t, no.
Q. And how were the updates communicated to staff?
A. So they would be on, essentially, the internal intranet as points that we needed to read, as well as SOPs being updated and guidance through — through that way.
Q. Are you referring to the coastguard information portal?
A. I am.
Q. And would you have had sight of every update?
A. Yes.
Q. And would you have to tick or mark that you had read an update, or was it down to your own discretion?
A. That certainly is the case now. I can’t recall if that was the case then.
Q. Let’s finish just on paragraph 6. So, the second line, end of line 2, you talk about the principles applicable to small boat search and rescue and you have said: “[It] largely follows the same principles but the difference with small boats was the volume.” So just pausing here. I think what you are saying here is that with small boat search and rescue, there were often multiple vessels in distress at the same time, perhaps?
A. That — that’s correct. Essentially, with normal search and rescue, you would have a first informant on the casualty vessel themselves make contact and they would give you — give you the information that you need, to prosecute an incident. With small boats, you had an unknown number of vessels leaving an unknown number of places with an unknown number of people. And therefore, the only thing you could do was attempt to saturate the area and rely on the phone calls and the information from the French to — to task assets appropriately.
Q. So you have just said that — the word I was going to ask you about actually. So carrying on in the same paragraph, fifth line down, you said that in terms of responding, you would — effectively, you would send as much resource as you could and saturate that area, to identify targets that you could then rescue. Can I just ask you what you mean by “resource” there?
A. So, in terms of resource, it could be aircraft, primarily, because they can move through the air. The Dover Channel is a significantly large area and a small boat is very small and as a result, air cover was — was an effective way of covering that — that area, yes.
Q. So by “saturate”, you mean to have cover, rather than to fill with surface assets, for example?
A. Yes, and I think it would be impossible to cover the entire area by aircraft alone, or vessels. You have to rely on the information that you are being given by — by the vessels, or by the French tracker, or by transiting vessels.
Q. In November 2021, did you consider that HM Coastguard had sufficient assets to saturate an area to find small boats?
A. Based on the information, as we got it, I would say, yes. But there was always limitations because pilots have limited hours, vessels have limited hours. You can’t stick 20 boats out at sea for 24 hours to capture — to — to meet any vessel that comes across. It’s impossible. There just wasn’t the resource for that and I don’t …
Q. In part of your response to coastguard’s internal review — you were interviewed — you said that sometimes there can be a lack of understanding what assets are available at Dover. What did you mean by this?
A. So essentially, small boats was very new to everyone and there was a lot of change in response to the volume, as I have touched on, that normally — you know, search and rescue, normally, there would be one or two vessels at most and not having an idea of how many vessels there were, meant that with the vessels that we were tasking to things, they — they — we couldn’t put them out all the time. Sorry, could you ask the question again, sorry?
Q. Yes, so it’s about what you said in your internal review interview. You said: sometimes there can be a lack of understanding of what assets are available at Dover. Does that refer to Border Force assets, or?
A. Yes, primarily. Due to limitations at the — at Dover itself, in dropping people off, and getting them back out to sea. Sometimes it could take them half an hour to drop the small boat — the casualties off, but sometimes it could be two or three hours, the — in Dover port. So that was — it was a real challenge and we tried to work on lots of different ways of understanding how long it would take another asset to get back out to sea after recovering —
Q. (Overspeaking) I see. Assets could get tied up at Tug Haven, say?
A. Absolutely, yes. Yes.
Q. You have told us in your statement, paragraph 7 — it is still on the screen — that you went to Dover about five times.
A. Yes.
Q. You stayed for several days at a time. So you have obviously had experience of working at Dover as well as remotely.
A. Yes.
Q. So were you — maybe this is the right question, maybe you were — were you aware, then, of those staff shortages at Dover?
A. I don’t think I was aware of the staff shortages at Dover. I went because I felt it was important as an SMC who worked remotely, to get that experience. It was also to help bolster the numbers there, but that wasn’t, necessarily, the primary reasoning.
Q. So you didn’t respond to an advert for coastguard staff, to go and —
A. I didn’t. I went a number of times and I think maybe on one occasion, I did. But for me, it was more being proactive and to get experience so that we could provide remote SMC as the port required.
Q. Was this in 2021?
A. I believe so, to my recollection.
Q. And did you experience shifts with high boats — high small boat activity on any of those trips?
A. A significant amount.
Q. Finally, on your experience of small boat search and rescue, you and other witnesses have told the Inquiry that callers from small boats sometimes exaggerated their level of distress. Can you tell me what the basis for that belief was in November 2021?
A. So, the belief was based on experience. An example being only a few weeks prior, we had a call from a small boat that said that there were three children in cardiac arrest. We moved helicopters and assets to — to help them. And we found and were greeted with predominantly men sat waving at the helicopter. No children on the vessel. I don’t — I sympathise with — with people exaggerating what is going on, on board, but it made our job infinitely difficult. There was no way we could triage the vessels because, as I said before, we don’t know how many vessels there are, we don’t know how many people there are. And by them saying that there are children drowning, that there are people falling off the boats, you do your very best to get assets into that area as quickly as possible. And, nine times out of 10, in fact, almost on all occasions we would find that they were safe and well. You know, they were making way towards the UK and there was no distress — you know, no persons drowning or having heart attacks or having babies, or no persons that were missing from the craft that we could find. And that takes its toll on people, that really does, especially people receiving those 999 calls. It’s — it makes our job infinitely more difficult.
Q. So nine times out of 10, vessels weren’t in a real emergency situation?
A. Well, I think — they are in a very busy waterway. They are potentially taking on a bit of water. They are in a very uncomfortable position. And that’s pretty horrific for them and I feel — my heart goes out to them. But, no, they — they weren’t drowning, they weren’t in cardiac arrest, and, you know, on many occasions, in fact, almost all other than this one that I have been involved in.
Q. And nine times out of 10 then, you are saying that there would have been exaggeration?
A. Yes, there would have been exaggeration.
Q. In your experience?
A. Yes.
Q. And was this something that you talked about with colleagues?
A. Yes, it was. But it didn’t change the way we responded to the vessels. Ultimately, we sent a vessel — sorry, we sent assets, you know, helicopters, aircraft, vessels to the locations that we believed people to be in. It didn’t change the way we responded.
Q. Did it change the way you thought about the vessels or you thought about the level of distress?
A. No, no. I have it take everything on what I am being told, at the end of the day. That’s how we — we deal with things in the coastguard.
Q. So you took everything at face value that you were told?
A. I have to, yes.
Q. I want to ask you now some questions about HM Coastguard’s system of network flexing, or remote cover. Paragraph 9, if we could just keep the witness statement up, please, {INQ010140/4}, second sentence, you say: “Remote support to other [MRCCs] is often provided from the JRCC. As the JRCC is a central point of contact, it is well placed to assist other stations across the network when assistance is required.” Can you just explain what it is about being a central point of contact that makes the JRCC well placed to provide the remote cover?
A. So historically, the JRCC had additional staff that were available to support other stations as and when the network required it. We had a number of SMCs available to cover SMCs. Obviously, when people go sick or when there are other issues, we would take on those — those zones, as we call them, in the coastguard. We would have the same — use of the same systems, like ViSION and we would load those zones, the same as the MRCC. Let’s say — let’s take Belfast, for example, we would load the zones that Belfast have, so we can see all of the incidents they have. We can support and give guidance and give direction to the staff for SAR cases. Yes.
Q. And how would you communicate with the station that you were providing remote cover for?
A. So we would use a TalkBox, which is essentially an open line available to all the staff to load and we can communicate like that.
Q. And were those communications and TalkBox recorded?
A. I am unaware of that.
Q. You’ve told the Inquiry in your statement that the only thing you would miss, as a remote SMC, would be any in-person discussions?
A. Yes, that’s correct.
Q. Could missing these in-person exchanges of information, impact on your oversight of a mission as SMC?
A. Are we talking about small boats, or are we talking about in general?
Q. In general, but — well, both.
A. The expectation is that people would enter their thoughts into the log in ViSION. So my expectation, is as trained operators on the other end of the TalkBox, is that they would put those things in. Ultimately, as the SMC, you are the decision-maker and any information that’s pertinent to the SAR case would be written, or should be written in ViSION.
Q. So anything relevant is in the log, so you don’t miss anything relevant?
A. Absolutely. We shouldn’t do.
Q. But with small boats?
A. As, as — are we talking about the evening — that evening?
Q. Generally. I mean, what the Inquiry has heard is that due to the volume, sometimes it was difficult to record everything in ViSION?
A. That is — it was difficult to record everything in ViSION, but when it comes to small boats, there was also the tracker. And that was a very clear — that was a document that was very fluid and information from ViSION was transplanted in there, both for Home Office colleagues, but also — I don’t know if you have seen ViSION, but ViSION, when you have got small boats, a lot of red incidents and sometimes it can be quite difficult to navigate that. And my view, and the view of other SMCs, is that the tracker is a good tool to use, so that you can see, you know, if you have got 30 migrant incidents, you have 30 lines to read, rather than with ViSION, you have lots and lots of red boxes, that you would have to go into and review. Whereas, the tracker is one line per incident and it gives you, essentially, a summary of what is going on.
Q. So with small boat search and rescue, as a remote SMC, you could rely on the tracker to give that kind of oversight?
A. I would use both. I would use both.
Q. And in terms of your — what you referred to as the pastoral role or the team leader support role —
A. Yes.
Q. — how effectively could you support, let’s say, trainees, or recently qualified MOOs, as a remote SMC?
A. So in terms of the pastoral care, I would — I would expect their team leader or their SMC that would normally be there, to do it. I would communicate with them after the event, via email. I would check in on them as much as I could, but I can’t physically be in Dover to speak to them. But I would certainly signpost and/or flag any concerns about their welfare to other people.
Q. In your view, was regular remote support from the JRCC an effective solution to the staffing problems in Dover in November 2021?
A. I don’t know if there were staffing problems in Dover in 2021. I think remote SMC was an effective tool to ensure that there was oversight of small boat activity and other search and rescue during that period.
Q. Before we move on to your involvement in the night in question, I want to ask you about two other support tools that HM Coastguard use specifically for small boats. We have already touched on one, which is the tracker and the other is the mobile phone, the coastguard’s mobile phone. So let’s look at the tracker first. What I want to understand is how the tracker worked in practice. So, it is an operational support spreadsheet —
A. (Nods).
Q. — used by coastguard, as you have said, to keep information on small boats on one page. You said it was very easy to see —
A. It was a snapshot of each incident, yes.
Q. Contrasting with ViSION with all the red boxes and much — much more dense information.
A. Yes.
Q. Do you know — you know what I am talking about, when I mention the tracker. I don’t need to show you a version?
A. No, I know what the tracker is. Yes.
Q. So in your statement you have said who had access to the tracker.
A. Yes.
Q. Those at Dover, the Maritime Tactical Commander, you, and a colleague at the JRCC, this is on night.
A. Mm-hm.
Q. And perhaps if we look at paragraph 34 {INQ010140/14} of the statement, please. You said that the practice was that the tracker was updated any time that an incident was created or updated in ViSION.
A. Yes.
Q. You have referred to it as a practice. Was this something which there was guidance on, or a policy on, or was it something that you did as something that was sensible?
A. I don’t recall, if that — I don’t recall.
Q. Was it something that you would tell your staff to do?
A. So, as I have said, small boats is an evolving situation and initially, only people at Dover had access to the small boat tracker. As I have touched on in my statement, I have said that the SMCs — myself and the other SMC on watch at that time, had access to the tracker. I believe at that time, that the other — the MOOs and SMOOs wouldn’t have, because they hadn’t had much, if at all — any exposure to small boats and, therefore, it was only given to people that — from my recollection, that needed to have access to it at the time.
Q. And would you expect everything that was on the tracker to have a corresponding entry in ViSION?
A. Yes.
Q. Or — you would. So for you, it wasn’t — you didn’t experience what I have referred to earlier where — the situation where there would be too many small boats to record everything exhaustively in ViSION and people would just be putting information in the tracker?
A. No.
Q. That wasn’t your experience?
A. No. We are receiving hundreds of pieces of information from multiple sources, including police, fire, ambulance the port authority, small boats, the French, passing and transiting vessels. And all that information is recorded — or should be recorded in ViSION. The small boat tracker was a snapshot of all of that information. If you can understand — if we can — sorry, if we can understand as an SMC, you have got to analyse all of that data and there’s got to be a way of presenting it to your team, or to people that are working on small boats in such a way that they can look at it and have a clear understanding of which asset is going to which vessel, or what we believe to be the vessel. Whether they are, you know, one of the small — one of the Border Force vessels, back at the Tug Haven, replenishing or changing crew. It was a snapshot; so all of the information should be in ViSION and the snapshot was the — the tracker.
Q. Okay. And you have said, paragraph 35, you had the tracker open at all times, although perhaps not visible at all times, it was on one of your screens?
A. Yes, essentially, we have four screens, as a standard operating to access. And two of those are taken up by the ViSION system. You also have — in the incidents of that evening, I would have had long-range search and rescue, so I have an email box. You also then have Internet Explorer, so you can access some of the coastguard databases and you would have the tracker. And yes, as SMC, or involved in small boats, I would try and keep that on the front page, as it were, at all times. But sometimes when you are trying to gather information from other sources, that would fall behind. But it was my primary — certainly, my primary point of — of — to view.
Q. And then paragraph 36, at the end of this page and going over to the next, {INQ010140/15} you explain how on night in question, you allocated one of your team to have oversight of the tracker that is. Can you explain what you mean by “oversight”?
A. So in this instance, I asked the other SMC that was in the room to keep an eye on the tracker for any obvious mistakes. That’s quite a difficult task because we — remember that Neal was the SMC in Dover, but I was aware that he was — there were calls coming in and sometimes, as you can imagine, with an Excel document, things might be put in the wrong box. They might be moved, deleted — you know, there are potentially 30 to 40 people in the tracker. And what I meant by that was for him just to keep an eye on the incidents in ViSION and kind of ensure there was correlation between the two. It is worth noting though that that individual needed a break, so they would have left for an hour and a half. They also need to go and cover our MCC function which deals with beacons. So it would have been a comment to keep a look in, while I went back to my duties looking after Solent Coastguard and Falmouth SMC.
Q. And just as an example of what an obvious error is, are you talking about something which, on the face of the tracker document itself, was obviously inconsistent?
A. Yes. Yes.
Q. So it wouldn’t mean an error which was on the tracker which was inconsistent with information in the ViSION logs, for example? You wouldn’t be expected to look at ViSION logs?
A. Not necessarily. You know, Neal and Stuart were doing that in Dover, that was their role and function. It was just, in my view, a safeguard to — to support them, should something glaringly obviously — because you have got to remember that Border Force were making decisions about their assets based on that tracker as well and therefore, it needed to be as accurate as we could make it, whilst it was a fluid document.
Q. And did you tell Neal Gibson at Dover that you had someone overseeing the tracker at the JRCC?
A. I may have done, but I don’t recall.
Q. Would it have been something that you generally would have told him, that he would have needed to know, or …?
A. Not necessarily. Not necessarily. I –I was SMC to begin with, so there I have a vested interest. I might have been doing it at the time, but you want to support your colleagues and you want to make sure that we are getting the right outcome for people that are out at sea.
Q. So would this person overseeing the tracker, would it be a kind of second pair of eyes function?
A. Essentially, asking him just to keep an eye on it, and yes, my expectation that if he found anything glaringly obvious, he would have made contact with Neal to discuss that.
Q. Do you know if that’s what — something that coastguard did more generally, or was it something that you thought, in your particular team and your role, that would be useful?
A. I — I don’t think it — I don’t know if it was something more generally done. But ultimately, in Dover, there were normally more people and, therefore, they would have oversight of their own tracker. But in that instance, obviously there wasn’t a significant number of staff and, you know, I like to make sure that people are okay and we are looking after them.
Q. Same paragraph, 36, third line down, you have said already that Neal Gibson would have had the overall responsibility for the tracker being SMC at Dover. You referred to his — the staffing problem on the night, if not in general. Do you think he would have had sufficient time and resource to have overseen it himself to any meaningful degree?
A. My recollection is, based on the volume of calls that I saw through our system, that he would have done, yes. It’s worth noting I have since learnt that he was on a phone call for an extended period of time. I was unaware of that up until only a few months ago. And if I — potentially, if I known differently, then I would have kept a closer eye. But ultimately, no, he would have kept on top of it.
Q. When you say the phone call, can you be more precise, which one you are talking — is it a 20-minute call with —
A. Yes.
Q. — with Moomin, is that the call?
A. Yes.
Q. Yes. Were you aware of the Border Force having access to the tracker by 23 November?
A. I believe so. That’s my recollection, of seeing the names and their email addresses bounce around the boxes.
Q. And do you have any recollection of Border Force being asked to fill in certain parts of the tracker by that time?
A. I am not sure by that time, but at the end of the lines, there are points for Border Force to add tallies of persons that have been recovered and things like that —
Q. Were you aware that they — or did you have any recollection about them being asked to add the M number, or the Border Force reference number, into the tracker?
A. That — usually, from my recollection — and it’s difficult because of the passage of time — is that something that we were given and we would enter into the tracker.
Q. The final piece of general information I wanted to ask you about is your awareness of the HM Coastguard mobile phone in November 2021. You know what I am talking about when I refer to this the iPhone that Dover had?
A. Yes.
Q. So you were aware of the mobile phone when you were at Dover, presumably?
A. I was aware it existed, yes.
Q. Did you ever use it whilst you were at Dover?
A. Not, I –I saw it in use, but I didn’t use it myself.
Q. Did you receive any training or guidance about its use?
A. I think it was primarily focused on Dover, so I don’t believe so, at the JRCC.
Q. And I suppose that’s the next question really. I want to understand how the HM Coastguard mobile phone worked with remote cover because what I understand about it is that it wasn’t integrated in HM Coastguard’s systems. So how did it work, if you were providing remote cover, keeping an eye on the mobile phone?
A. So obviously, I wouldn’t have any oversight of the mobile phone. It would be down to the operator in Dover for — only during small boat activity. It wasn’t part of any other systems. Small boats, as I have said before, was an evolving situation and we were trying to find solutions to a problem that existed that we really hadn’t faced before. You know, we have a phone call from someone, they don’t know where they are. The phone system cuts out left, right and centre because the network is not designed to cover the English Channel and therefore, we really struggled to get information from the small boats themselves. And likewise, because there were — a lot of people, from my understanding, were using foreign SIM cards. They didn’t have data, so couldn’t get any GPS position. Initially, we looked at all the different ways you could get a GPS position from an iPhone. We looked at solutions around that. But we found, more and more, that they just couldn’t tell us where they were. And none of the systems that we have built into our system would work with a roamer phone or a foreign phone. So a solution was found that, I think, probably someone learnt from the French that they could use that to get a position. Now, you know, my expectation is any information from that phone would be input into ViSION and then correspond to something in the tracker.
Q. So that’s how it would work, as a remote SMC that you would rely on ViSION —
A. Yes.
Q. — that those at Dover to be putting anything relevant from the coastguard mobile phone —
A. Yes.
Q. — into the logs and then you would see it?
A. Yes, during small boat activity, that’s correct.
Q. Let’s now move on to the night in question. So your shift at the JRCC was around 07:00 til 19:00, as I understand it?
A. That’s correct.
Q. I want to show you the transcript of a call just gone half past seven in the evening on 23 November. It’s {INQ010128/1}. This is a call between you and Neal begin you can see the time there, it was shortly after you both started your shift so if I could go on to page 2 {INQ010128/2}, please. You call Neal Gibson. He says he is running around like a headless chicken. You say: “Okay I’m just trying to work out a plan for this evening.” He says: “Assemble all your staff, express freight to Dover ready for 01:00.” You say: “All right.” He says: “Get them … in the staff car … should take about 2 hours … Get them here, we’ll all be sorted, happy days.” Obviously, an element of levity there, but underlying that, was Neal Gibson suggesting here that he really needed people in the ops room in Dover and not in the JRCC?
A. I think that’s what he might have been implying. But that was, you know, Neal’s take on it.
Q. Insofar as you are able to say, why do you think he would have wanted people on the floor in Dover, as opposed to remote from Hampshire?
A. Because it’s often easier to have staff under your direct supervision.
Q. Obviously, no one went down. But you were relatively heavily involved in Dover’s work that night, it’s fair to say, I think?
A. At the beginning, yes. Yes.
Q. We can take that transcript down now, thank you. In your statement, you summarise your duties that night. Perhaps let’s bring that up again, paragraph 19. {INQ010140/6}. There we go. So paragraph 19, you say: “I had oversight of all staff on shift at the JRCC, as the team leader …” You also refer to oversight of long-range search and rescue, just very briefly, that’s not to do with small boats?
A. No, that’s for incidents happening in the North Atlantic or worldwide.
Q. Okay. You then refer to your involvement at Dover, SMC cover.
A. Mm-hm.
Q. And then further involvement, but not as an SMC. And then fourth line, you say you were SMC for Falmouth for a period.
A. Yes.
Q. And I think you also said that you were also SMC at Solent —
A. Yes.
Q. — throughout?
A. Yes.
Q. Yes. Do you recall when you were SMC at Falmouth?
A. So I believe I was SMC from Falmouth when Neal took back SMC around half past 1 in the morning. We would have planned it probably from 3 o’clock or later. There was another member of staff that had SMC on the watch, but we had a few duties to cover between us, including getting him on break. And so, yes, I would say it was planned from 3 o’clock.
Q. It sounds like a lot of hats and a very busy night, is that fair to say?
A. Yes. But the role of an SMC is to prosecute SAR incidents and if there were no SAR incidents, then the pastoral element remained and the welfare of the staff. And if, for example, I had been bogged down with incidents in, say Falmouth patch, in the Bristol Channel, I would have contacted the network commander and asked for some assistance and potentially, looked at getting another SMC to take over some of that workload. So whilst I had a lot of hats, it is only a lot of hats until such time that there is an amount of search and rescue.
Q. So, busy but not unusually busy and nothing that you couldn’t cope with?
A. Quite normal.
Q. Normal. So, paragraph 20, end of the fourth line {INQ010140/7}, you explain what you mean by overseeing the staff. You say: “When I …oversee the staff, I …mean oversee all of the incidents and [ensure] we are taking appropriate action to make sure the incidents resolve with a positive outcome.” Would this summary of the function of SMC, or team leader, apply generally to all SMCs and team leaders?
A. Which line was it from, sorry?
Q. End of fourth.
A. End of the fourth line.
Q. So “when I say”, you see it there: “… I really mean [I] oversee all the incidents and [ensure that] we are taking appropriate action …”
A. Yes, that would be the case for SMCs at all MRCCs around the country.
Q. Is it right you also had a trainee at the JRCC on the night in question?
A. I believe so, yes.
Q. You say this person was non-operational and they were essentially observing.
A. Yes.
Q. Is that what you would expect of a non-operational trainee, that they would be essentially observing?
A. If they have not got a comms ticket then yes, and I would have probably assigned someone to support them through night on their training, and they would be listening into calls observing, like you say.
Q. The comms ticket is the communications qualification?
A. That’s the first qualification that’s done in the coastguard, yes.
Q. Once you had that, then you could answer 999 calls, for example?
A. Absolutely, under the supervision of — of an SMC or SMOO, yes.
Q. Moving, then, to your involvement with Dover. Paragraph 21, first line, you say that from half past 10 until midnight, everything moved to the JRCC. And that’s because both Stuart Downs — well, Stuart Downs was on his break and Neal Gibson was covering VTS?
A. That’s correct.
Q. And then you say, line 4, Neal Gibson did a handover. It was routine as there were no small boats incidents at that time?
A. Mm-hm.
Q. And then you had a two-hour period between 10.30 and midnight — sorry, about half past midnight, when you were providing remote cover at Dover, correct?
A. Yes.
Q. Paragraph 24, just moving down slightly {INQ010140/8}, you had no contact with Neal Gibson whilst you were providing the remote cover. And then when he returned, you became the SMC again. Sorry, he became the SMC again.
A. Yes.
Q. And you say, third line, you expect you would have had a brief discussion to discuss matters. What would you have discussed on that call? What would have been the —
A. So I — I don’t recall the conversation that we had, or if we had it, but —
Q. Would it have covered your continuing role in the night and what the JRCC would be doing as the night went on?
A. Neal wouldn’t have been interested in what I was doing in terms of the JRCC or Falmouth. He would —
Q. In terms of involvement in Dover, because once he —
A. Yes, yes.
Q. — once he became SMC again, you still were involved throughout night?
A. Yes, he hit the ground running and there was — there was three incidents open at the time. And I think that he, from what I can see from the information that’s been provided to me, would have got back to his desk and essentially, picked up a call and got involved quite quickly, which would have probably shortened or stopped the conversation we would have normally had to share information. My view on that is that there was only three — there was only — there was three incidents open at the time and all of that information was clear for him to see, in both the tracker and in ViSION. You know, if there had been 30 jobs open, then there would have been a need for a more significant handover.
Q. And you say then, still paragraph 24, penultimate line, that you would have been in fairly regular contact with Neal Gibson after he came back.
A. Yes.
Q. Would that have been via talk, primarily?
A. That’s correct. I did try and contact him on a number of occasions, yes.
Q. Let’s now talk about the period of remote SMC cover, so the two hours between 22:30 and 00:30.
A. So 22:30 to midnight would have been us having the entire station at the JRCC, so it wouldn’t have been remote.
Q. I see, so the remote cover came for the half an hour —
A. After that, yes, for when Stuart was on his own, yes.
Q. Yes, so let’s call it the JRCC taking —
A. SMC.
Q. — taking control.
A. Yes, yes.
Q. And then you had a — half an hour of remote SMC cover?
A. Yes.
Q. Now, you have drawn up a chronology in your statement, but before we get to that, I just want to speak about the French tracker —
A. Yes.
Q. — which was received just before 1 am, which is when you were — well, you may have still been at the JRCC at that point. So the French tracker, you know where that was, an operational support spreadsheet. It showed that the French had been aware of small boat activity for several hours before they sent it on the night.
A. Mm-hm.
Q. And the Inquiry has seen evidence that this problem of delays in receiving the French tracker wasn’t new in November 2021. Were you aware of the problem of frequent delays in receiving the French tracker?
A. Yes, I –I believe I was.
Q. And would you ever call, when you were — when the JRCC was providing cover to Dover, would you ever call the French to check in, to see if there was anything?
A. So I — I can’t recall doing it on the evening, or if I did or I didn’t. But, yes, we regularly did. But you must understand that you are calling another country who are professional coastguards and ultimately, asking them for information that they have agreed to share with you. There was only so many times you can call before they see you as questioning their professionalism and as such, knowing how we deal with small boat incidents, and how busy it can become in the first instances, I think, you know, they are in the same situation, just the other way. And therefore, the tracker would come when they could get the tracker to us. That’s my belief.
Q. So there is a — in your view, perhaps likely reticent to actually do that call. It would be maybe questioning their professionalism or annoying them on some level?
A. I guess so, yes.
Q. When you started your remote cover, you were aware of a trainee at Dover that night also?
A. Mm-hm.
Q. Neal Gibson has told the Inquiry in his evidence that this person had only been with HM Coastguard for 30 days at that point. Did you have any direct contact with that person?
A. I don’t recall having any contact with that person. But it’s worth noting that whilst Neal was doing other duties, he was still in the same room. And that individual’s welfare would have been met from the SMC, Neal being — obviously, he wasn’t SMC at the time. But she wasn’t sat — they weren’t sat on their own, you know, isolated. They would have had support from both Stuart and Neal and the other guys on VTS, should they require it.
Q. Sorry. As with your own training at the JRCC, would you expect this person to be essentially observing?
A. Yes, I would have done.
Q. As for Stuart Downs, the MOO, he was operational that night.
A. He was.
Q. Insofar as you were aware, what was his qualification status in November 2021?
A. My belief was he had comms — his comms ticket.
Q. So he passed the communications qualification that allowed him to take the 999 calls and operate —
A. Yes, I believe he completed his coastguard training, but Stuart’s background — he’s had a career in the Armed Forces and the police. So he wasn’t someone that had come to call collection or data analysis fresh. You know, he had a lifetime of experience in that sort of thing. So in my eyes, he was a trusted pair of hands to be able to pass information to me in an appropriate manner.
Q. Let’s look at your chronology now. So this is paragraph 26 of the statement. You refer to the ViSION incident logs in your chronology. Just to confirm, is this how you refreshed your memory for the times, etc?
A. Yes.
Q. You used the ViSION logs to do so?
A. (Nods).
Q. The first entry there at the top, if we could just go down to the next page {INQ010140/9}, was Incident Alpha. And this was the start of your involvement with small boat search and rescue on the night.
A. Mm-hm.
Q. And you have said that Stuart Downs called you in relation to Incident Alpha around half past midnight. The call cut out before it could be transferred, but Stuart Downs obtained a number. And then this incident was downgraded from distress to monitoring, on the basis of the ringtone, which was not a UK ringtone. What was your understanding of the accuracy of using a ringtone to determine whether a person was inside UK waters or was still in — the other side of the median line?
A. My understanding was that — that a handset would connect to the — or have a preference to the network that it had previously been connected to and therefore, that would give a suggestion that they were in French waters. But, there would — you know, in this instance, there was no information of where this person, this vessel, could be in the English Channel. And, therefore, because it was the first call, historically, from my experience, people would start calling from small boats the moment they hit the water because although they were told by people to call when they got towards the — towards England, obviously in a panicked state and in the situations they found themselves in, they would regularly call moments — you know, for them, it may have seemed hours, but the reality, it may have been 20 minutes of a two, three-hour journey across and therefore, a lot of the initial calls we received, would place people on the beaches in France, in the 30 or so miles that they would launch from.
Q. So you were used to receiving calls whilst small boats were still in French waters?
A. Absolutely, yes.
Q. Let’s then look, very quickly, at Incident Bravo. Your involvement here was limited to confirming that there was an error in the French co-ordinates which meant that the vessel was not already in UK waters. Then bottom of the page, Charlie. So you were providing SMC cover when Incident Charlie was opened?
A. That’s correct.
Q. And you say that this was a call received by Stuart Downs where the caller reported 30 people on board and the dinghy was in good condition. You say that Stuart Downs discussed this with you and you would have asked him to contact Border Force due to the proximity of the vessel to UK waters.
A. Mmm-hmm.
Q. It was then confirmed to you that the Valiant was deployed. Perhaps we can just turn up the Charlie log. So this is {INQ000237/1}, page 3 {INQ000237/3} of that. You see the entry from Stuart Downs there, right at the bottom of the page?
A. Yes.
Q. The 01:19 entry. Is that where you would have got your information from, for the purposes of making the witness statement?
A. That’s correct.
Q. And we know from the call logs that, in fact, where the information about Incident Charlie was received was in fact, in a call at 01:06, so not at 01:19 and it was actually the trainee in Dover who made the call to French coastguard. So not Stuart Downs. Were you aware that the trainee made a call to French coastguard?
A. I wasn’t — I don’t recall that.
Q. And who would have asked her to have done that, do you think?
A. I would — I would be speculating. I don’t — I don’t know.
Q. But it wasn’t you?
A. I don’t believe so.
Q. Do you think it was appropriate for a trainee who was essentially observing, to be making calls to French coastguard?
A. I don’t — I don’t know the answer to that. I don’t …
Q. You don’t know if it was appropriate?
A. I don’t — I don’t think it was appropriate — it would be appropriate.
Q. And just to confirm as well, your understanding of Incident Charlie, at that time, was from the ViSION log, presumably?
A. That’s correct.
Q. Which said, as we can see in the bottom right, right at the bottom of the page: “Dinghy appears in good condition.” Yes?
A. Yes.
Q. So that ended your remote SMC period and after Neal Gibson returned to the operation room, we know that you continued to provide support to Dover, but not as an SMC?
A. That’s correct.
MS MOFFATT: Sir, I am just looking at the time. I don’t know if that’s an appropriate point to take a break.
SIR ROSS CRANSTON: Yes, yes. Just a short break. 10 minutes, thanks. (11.56 am) (A short break) (12.05 pm)
SIR ROSS CRANSTON: Yes, Ms Moffatt.
MS MOFFATT: So let’s return to the chronology, page 10 of your statement, so if we could just put that on screen again, thank you, {INQ010140/10}. We can see there three incidents, Delta, Echo and Hotel, there we go, which you created on the basis of a call from the French coastguard?
A. (Nods).
Q. Then, next page, page 11 {INQ010140/11}, we see Incident Lima. And you say that your colleague at the JRCC took a call on Lima and at 02.48, you added details to CSCOPE and that’s software used to predict small boat tracks towards UK?
A. So it’s an AIS tool that we use to see vessels transiting the area and we can add targets, as we call them, which are simulated tracks of small boats to give us a clearer indication of where they are heading and where they might move to.
Q. So in order to add them in, you would need information on position, speed and course?
A. Yes.
Q. Would that likely have been obtained from French coastguard?
A. So it says here that my colleague took a call from Incident Lima. So I can’t — I don’t know if that came from the French coastguard without looking through the log, but it could have done, or it could have come from the vessel itself, but it would be very difficult for them to —
Q. (Overspeaking) It would be quite unlikely that they would give you course and speed.
A. Yes, correct.
Q. Yes. And then you say that you —
A. Sorry, I say it is provided by the French in that — in the statement there. This was because we had the time, position, course and speed provided by the French.
Q. Thank you. And then you say that you changed the phase to distress because it was very close to UK waters and to alert Neal Gibson, SMC at Dover.
A. Yes.
Q. Would this have been the first time that Neal Gibson was alerted to Incident Lima?
A. If my colleague at JRCC had taken the call, with the volume of calls, it was unlikely he would have monitored the call, therefore yes, the ViSION log, he would have seen it there; that would be the first time.
Q. Then at the end of the box, you say you had no further involvement in Incident Lima?
A. I don’t believe — that,s — yes.
Q. Did you know that Neal Gibson identified Incident Lima as the first small boat embarked by the Valiant that night?
A. I didn’t — or I don’t, no.
Q. Would you have expected to be told, given your involvement?
A. No. My role very much was a supportive role. I was there, in a sense, to take any calls that weren’t being answered and — answered and put the information into ViSION, into the tracker, as per the previous incidents, the reference in my statement. I took a call from the French, I took the information from them and I entered it into the ViSION log so Neal had awareness of it.
Q. So it was essentially a role like akin to MOO?
A. Essentially, yes. I had other responsibilities and I — if I became too embedded in small boat activity, then my focus would be taken away from other incidents, which then could lead to other consequences.
Q. Let’s move down then, next page, page 12, Incident Charlie again {INQ010140/12}. You explain you had involvement again at 03:25 when you spoke to Valiant.
A. Yes.
Q. Valiant hadn’t found Incident Charlie at the Mayday Relay position and they said they would go in the direction of the drift to try and locate it.
A. Yes.
Q. And you say that you recorded in the Charlie log this — what had happened, the Valiant had found two potential targets. Did you believe, at that stage, that one of those was likely to be, or was Incident Charlie?
A. That’s what I believed, based on the information I had received. Yes.
Q. Then, at the bottom the box, you say you had no more involvement with Incident Charlie after 03:39 in the morning. I think, by this, you mean that you had no more — you made no more entries on the Charlie log.
A. Yes.
Q. Because you are recorded as making an entry on the shared tracker against Charlie shortly afterwards.
A. Okay.
Q. We will come to that.
A. Yes.
Q. You have talked about it in your statement. So actually, in your statement you say you don’t have any independent recollection of making this entry in the — not surprising, given the passage of time.
A. Yes.
Q. But you accept that your name is attributed to the amendment made at 03:57 and it is highly likely that you made it.
A. I would have made it, if that’s the case, but as — you know, small boats often — you know, I have done hundreds of nights of small boat activity in my career, as have others, and trying to recall things like this would be very, very difficult.
Q. But you have seen the index of versions?
A. Yes.
Q. You trust it? The IT is right?
A. Yes, absolutely, the IT is correct.
Q. Let’s then bring up the — that iteration of the tracker, so the one at 03:57 {INQ006802/1}. We will wait for it to come up. Okay. So this is obviously very familiar to you?
A. Mm-hm.
Q. What we can see, the addition that you made is in the “UKBF Ref” column.
A. Yes.
Q. The M957 there against Incident Charlie. So if we could just highlight that; that’s it, there we go. And in your statement you say it was likely that it was the Charlie ViSION log that was the source of that information.
A. Yes.
Q. Consistent with what you have said throughout the night, that you would be looking at the logs, that should contain all the information. Let’s then go back and look at the Charlie log again {INQ000237/1}, page 11 {INQ000237/11}, please. So we see at 03:50, about halfway down the page, Neal Gibson enters: “Valiant on scene with unlit migrant vessel 40 [persons on board], stopped in the water.” And then we see directly below, Stuart Downs, the MOO at Dover, entering the Mike number, M957.
A. Yes.
Q. You say that that was the Mike number that you then put in the tracker?
A. That would have been the trigger for me to put into the tracker, yes.
Q. And would it have been the fact it was on the Charlie log that made you put it against the Charlie row on the tracker?
A. That’s correct.
Q. Do you know why — you probably won’t be able to tell me this, but why did you not add the information at 03:50, the other more detailed information about Valiant being on scene? Would it have been normal to have put that in the outcome column or the notes column, or was that not relevant information?
A. I don’t know the answer to that question, I’m afraid.
Q. And did you have any doubt that the first small boat embarked by the Valiant may not be Incident Charlie?
A. I was not involved to that level of detail. As I have said, my role was to support and take information and present it to the SMC through the ViSION log and through the tracker.
Q. Were you aware, that night, that there were multiple, potentially four, small boats in the same area as Charlie, around the Sandettie?
A. I was aware of that, yes.
Q. You were aware, from the French tracker?
A. Yes, I –I am not entirely sure where I was aware from that — that from, but I was aware there were multiple boats in that location when we got there.
Q. And were you aware of a practice whereby when an asset is tasked to an incident, all information about that asset’s actions are recorded in the log of that incident?
A. That’s correct.
Q. So it may mean that several small boats appear on the same incident log. Whereas, potentially, that incident log may not relate to any of those small boats?
A. Yes, it’s important to remember that all of the small boats — or all of the communications that we receive are issued an alphanumeric number. So whilst we talk about Charlie, Delta, Echo, Foxtrot, Lima, what that actually references a point of contact from someone, fire, police, ambulance, French coastguard, that we designate that numeric number. So it’s quite probable in many occasions, and it has been seen multiple times throughout hundreds of evenings of small boat crossings, that Alpha, Bravo, Charlie, Delta are all the same. I am not referencing this one in this, but ultimately, we may — I think on occasion, we had about 85 — on one occasion, 85 or 90 phone calls and we had gone through the alphabet three or four times and those would be — then be attributed to other vessels earlier in the evening. So because you have got multiple people from every vessel in — from my experience, calling us and giving us information, it’s all very different and very differing. You know, you are trying to extract key information to try and ascertain their location, that is why we end up with so many different alphanumeric references. And it’s quite normal for Lima, Delta, Kilo to be the one and the same as Echo. But the reality is how would we ever — how can we categorically say that they are, or they are not? Because historically, people have thrown their phones overboard, they refuse to answer questions to Border Force around whether they have called us, for whatever reason, I don’t know. And therefore, it makes our job really difficult. It’s incredibly difficult to take all of this data and to — to make sure that we get every single person every single time because we just don’t know how many people are out there and how many people and where they are coming from, yes.
Q. On this occasion, you had the information there were four small boats all in the same area.
A. Mm-hm.
Q. And you know about the practice whereby everything — all the actions that the asset Valiant did would be recorded on the log to which it was tasked, to the Charlie log?
A. Yes.
Q. Did this not give you cause to doubt whether the two entries at 03:50 and 03:56 in the Charlie log were actually about Incident Charlie or about another small boat?
A. No, as I said, regarding the other SMC that I asked to keep oversight or have a look at the tracker, I was potentially, at that time, playing that role, to try and make sure that things were as they should be. So I didn’t have an in-depth review of each incident, but what I was trying to do, was support Neal and Stuart in making sure that the information on the spreadsheet was as accurate as it could be to help inform other, you know, Border Force and themselves.
Q. Did you tell — or is it likely that you told Neal Gibson that you had made this entry on the tracker? Would that be the kind of thing you would do?
A. I doubt it. Because he was dealing with other things and that is something that I would have put in for him, so that it appears, like I say, in the tracker that is — is manageable for him to review.
Q. And were you aware that Neal Gibson later identified the first small boat embarked by the Valiant, which was M957, as Incident Lima, not Incident Charlie?
A. I wasn’t.
Q. On night, you weren’t?
A. I don’t believe so.
Q. And just going back to the kind of errors that you have talked about that your colleague was tasked to oversee. Is this the kind of obvious error that should have been picked up, or not, in your view?
A. Not necessarily, because as I have explained, we are not — I am not in-depth into the incident log. I am reviewing the information that’s coming, essentially while spinning a lot of other plates, to try and aid and assist. So, no.
Q. And let’s just bring up another version of the tracker. So this is {INQ006808/1} at 05:30. Wait a moment whilst it’s brought on to the screen. So this is a bit later on in the night, still only M957, your entry there, against Incident Charlie. But what I want to look at is information for Incident Lima. So Neal Gibson, at this stage, added, in the Lima row, for the column entitled “Outcome”, so I think we need to move slightly to the right here. There we go. So for Incident Lima, you can see there, Neal Gibson added in: “Recovered by the Valiant 0436UT [C, presumably] boat abandoned and marked with strobe.” So from looking at that information alone, which included a time of recovery, would you, or anyone else looking at the tracker at the JRCC, have been able to realise there was an error and that M957 shouldn’t have been there, in the Charlie row?
A. Can you repeat the question for me, please?
Q. Sorry, it wasn’t very clear. So, from looking at that information that Neal Gibson added, so what was on the face of the tracker —
A. Yes.
Q. — would someone at the JRCC, you or your colleague, have been able to realise that actually, the M957 against Charlie was wrong?
A. I don’t think so.
Q. And just to finish off on your timeline, then — so, we can take that tracker down, thank you — the last involvement in small boats on the night that you had was to take a call from Incident November at 05:10 and you created an incident as a result; that’s what you say?
A. (Nods).
Q. And at 05:00, you say that another experienced SMC, Richard Cockerill, joined the watch in Dover in the ops room floor and you, at that stage, could retreat and go back to Solent or whatever else you were doing?
A. Yes.
Q. I just want to ask you about an email you sent at 05:00, so this is {INQ006728/1}. We need to go down to page 2 here, actually, {INQ006728/2}. There we go; there’s your email. It is an email from you to an email address NMOC.CHARLIEWatch@mcga.gov.uk. Whose email is that?
A. So, that’s a mailbox that would have done to my entire team, the aeronautical team and the commanders attached to that team.
Q. So JRCC, essentially?
A. JRCC, yes.
Q. Yes. What you say is, you have: “Captured these screen shots, thought it might be of some interest to some … and/or useful for a training slide or two. “A lovely expanding square by [the] R163 in the middle of the TSS [traffic separation scheme] with [Border Force] Valiant being guided onto small boat crossings and the use of simulated targets on …” CSCOPE?
A. CSCOPE, yes.
Q. So let’s just then look at the screenshots that you attached, or one of them, so {INQ006729/1} here, you can see the search pattern of the R 163.
A. Yes.
Q. The expanding square. You can see three small boats which are marked by black triangles and have the names against them and a time.
A. Mm-hm.
Q. Would the times be the times that the location co-ordinates were given?
A. That’s correct.
Q. So we see there Lima, in the middle — a little bit hard to see, but hopefully you can make it out. So that was the first small boat to be found by the Valiant. Delta, which is just slightly outside the expanding square, off to the left there.
A. Yes.
Q. That was a repeat of the Incident November, which was the third small boat found by the Valiant, M959. And also there was another one, Mike, which is just off to the left of Lima and slightly down, and this wasn’t identified as being picked up by the Valiant. And you can also see the Valiant, the blue and yellow triangle just off to the left of Lima and the pink square is Sandettie. So these three small boats, were they simulated using CSCOPE, then?
A. So the screen you are looking at is CSCOPE. It an AIS piece of software. What we do, as I have said, is we would input a target — a virtual target, so if you look at coastguard, the red triangle, that’s the helicopter, as you have identified, and Valiant. But some of the others are simulated targets that we have entered onto the system. Obviously, they are not real, they don’t exist in — as AIS targets out there. They are what we would expect the track of a vessel to have taken, if we have been given that information. So, we would set it at 6 knots at 000 degrees and that would give us some indication of the speed and distance that they had covered, which would aid us. It’s worth noting that we regularly are putting out broadcasts on channel 11 to transiting vessels to keep an eye out for small boat activity while it is ongoing. And if you look at ocean, on the left-hand side, you can see a bit of a radar pattern on it. And so that vessel would have been made aware, via VHF radio, that there were small boats in the area and our expectation is that as they are transiting that, the English Channel in this vicinity, they would be keeping an eye out. Often, we would call those vessels and ask them if they could see any small boats. But as you can imagine, being small, dark, black boats with very low freeboard, it’s very challenging in any sea state, or any condition, to see them.
Q. So these — these three black triangles, they are simulated?
A. They are simulated tracks, yes.
Q. And you said in your statement, that you added the Lima co-ordinates —
A. I believe so.
Q. — to CSCOPE. Would you have done the same for Delta and Mike, would that have been likely, or —
A. (Overspeaking) Potentially, I couldn’t say.
Q. And would Dover and Neal Gibson have had access to this same image?
A. He will have CSCOPE, yes, and he would see — network-wide, everyone — you know, people would be able to see that.
Q. So, he would see that someone, maybe you, had plotted up Lima, Mike and Delta?
A. Yes.
Q. And looking at R 163’s search pattern, insofar as you are able to answer, would you have expected R 163 to have found those three small boats?
A. I would — we have got to remember, there might not have been — Valiant has stated when they have got on scene, that there are a number of boats. But we have to remember that there may have been 20, there may have been two and until something was in the area, we have no way of knowing. And essentially, that’s what I would say is a multi-layered approach to search. And you would expect the helicopter and/or Valiant — you know, Valiant less so, to see the vessels. But the helicopter has a great oversight of the area and whilst the small boats are small, you know, the technology on board those helicopters is pretty good. And if something was in that area, I would have expected them to have found the vessel, or person, or life jacket, or any debris. Because regularly, the helicopters doing searches like that, would report anything that they saw, you know. If — if there was a vessel that had sunk, I would have expected to have seen life jackets, personal belongings, parts of the vessel. An example being 163 on another job around a similar time, there was a — they saw a seal, you know. So they have got a very good overview of that area. And so, yes, I would have expected 163 to have guided on Valiant, which I believe it did in another incident, to any small boats in that area.
Q. Delta or November, for example?
A. Yes.
Q. Yes. We can take that down now, thank you. Just to finish your involvement with Dover, I just want to put up the index of tracker versions on the screen, so {INQ007058/1}. It might take a minute, again, for the spreadsheet to come up. If we could just scroll down to 05:18, sorry, up a bit — a bit further up, sorry. Yes, there we go. So we see there, at the top of the screen, that’s the 03:57 entry on the tracker that we have already seen, when you added M957. Then after that, 05:18, 05:21, 05:22, and after that, no more entries. So fair to say that your involvement in Dover stopped after 05:22?
A. Around the time Richard came in, yes.
Q. Moving away, then, from the chronology — we can take that down, thank you — I want it understand what you were told about the condition of the small boat known as Charlie, or Incident Charlie. We have seen that the ViSION log initially recorded it as being in good condition and that’s what you would have believed?
A. (Nods).
Q. Were you ever informed that Dover had been told it was sinking?
A. No.
Q. And were you ever told that there were potentially people in the water?
A. No.
Q. And you have told the Inquiry that, given both Neal Gibson and Stuart Downs were answering calls, it wasn’t easy to speak with them about every incident. Is it fair to say that you weren’t being updated verbally after every call or development that they had in Dover?
A. I wouldn’t have expected to. Neal is an experienced and very good SMC and he would have been focusing on that. I am supernumerary and feeding extra and additional information in to support them.
Q. So you, in the absence of verbal updates, were relying on ViSION and the tracker, as you have told us, to inform —
A. (Overspeaking) Yes, but I wasn’t taking — sorry.
Q. No, go ahead.
A. I wasn’t taking an active role in search and rescue at that point.
Q. No.
A. I wasn’t creating search plans, I wasn’t tasking assets. I spoke to assets when calls were received and not answered because they were busy and I input that information, but I was not making any decisions. Therefore —
Q. And you have already said, you were acting in a kind of MOO role. You were inputting information into the tracker and ViSION —
A. Absolutely.
Q. — but you weren’t making decisions?
A. I am operating, essentially, as a MOO with an SMC hat on, just trying to assist.
Q. You are relying on updates in ViSION in order to update the tracker, for example, as you have told us?
A. That’s correct.
Q. You did know about the Mayday Relay?
A. I did.
Q. You have told the Inquiry that this was the first time, to your knowledge, that a Mayday rely had been broadcast for small boats.
A. Mm-hm.
Q. So, very unusual, presumably?
A. It was quite unusual, yes.
Q. And it would have stood out in your mind as significant on night, presumably, as well?
A. Yes, but I — my understanding — there was — you know, the justification for the Mayday Relay is, you know, in my view, correct.
Q. So what did the Mayday Relay tell you about the status or seriousness of Incident Charlie?
A. So, my belief was that the Mayday Relay was used to pool assets in the area and make them aware that there was potential small boat activity. Now, as I said, we deal with hundreds of nights of small boat activity and often it’s — it’s irregular for things like air cover not to be in the air. It’s irregular for us not to have.
Q. Irregular, sorry?
A. Irregular, yes. We usually have both the tracker and aircraft and some oversight before they reach the UK line. On this occasion, due to the weather, we didn’t and my viewpoint was that the helicopter tasking initially was to go out and to — to try and get eyes on and to search the area for any suspected migrants because, as I said before, there could be four boats or there could be 20. The Mayday — my view of the Mayday was that Neal had put it out because we had nothing there at the time and by using a Mayday Relay, vessels in the area would be made aware and whilst we are putting broadcasts out on channel 11, it would highlight to them that we really needed them to do something, whether that was a commercial vessel putting people on the side and looking out, or checking their radar screens for any small targets or blips that they would normally have disregarded, it would have made people hyperaware of what was going on in that area. And there were a number of vessels in the area that could have given us eyes on, because you must remember, we are essentially blind until such time that we — we base our taskings on the information we get, but until we have an asset on scene, it is very difficult for us to really know what’s happening or how many boats or people, or the situation they find themselves in.
Q. So at that stage, when you — when you knew the Mayday Relay was being broadcast, would it be fair to say that it could have been one of those nine times out of 10 exaggeration?
A. Correct, yes.
Q. So you were using it to get situational awareness, essentially?
A. Absolutely. We are using it as a tool to raise awareness to other people, to give us situational awareness of what is going on in that area.
Q. Did you and Neal Gibson believe that the vessel was in need of immediate assistance?
A. I didn’t have any belief of what the vessel needed or did not need. That — Neal was the person, as the SMC, that had that. I don’t recall having a conversation about it sinking, but, you know, it’s an effective tool that we use in search and rescue every day in other circumstances, that we don’t often use in the Channel. But on this occasion, because there was nothing there, and because there was a belief that there were vessels in the area, it was an effective tool to get an insight.
Q. Is it an accepted use of the Mayday Relay procedure to use it for surveillance purposes, essentially?
A. I wouldn’t say it’s surveillance. But yes, we want to get a greater understanding. For example, if an EPIRB, which is a positioning device that’s on a commercial vessel or a sailing yacht, goes off, we would put a Mayday Relay out asking vessels to proceed to that area. Because they will be the first people there. Our lifeboats — sorry the lifeboats that we use and our coastguard helicopters and things are very, very quick at responding. But often, you will find that a vessel of opportunity in the area is — is often the vessel that will be able to give us an insight into the situation and render assistance to anyone that they, potentially, will find in the water, or needing assistance.
Q. So it’s uncertainty then —
A. No.
Q. — that causes it — essentially, the level of uncertainty meant that a Mayday Relay was necessary, or …?
A. No, I think that because there had been — or there was a belief that there were multiple vessels in the area, Neal had determined that that was an effective tool. I guess you could say it was uncertain. He — but he was trying find out what was going on in that location.
Q. Yes.
A. And the best way of doing that was to use all assets that we had and/or vessels transiting the area.
Q. Might that have been — so we know on night, that the distress — DSC alert for — Pan-Pan was used.
A. Yes.
Q. Not urgency. Might that have actually been an explanation as to why the Pan-Pan was used, because it was —
A. No.
Q. — trying to —
A. No. My belief is that that was an oversight, and that was a mistake. But I — to be clear, as a sailor myself and as someone who spends a lot of time on the water, a DSC alert, either alert or distress, will cause an audible alarm on the bridge of a vessel. Now, we have seen that there were a number of vessels in the area and it would be an expectation they would have someone on the bridge on watch and therefore, they would manually have to go and interact with the radio set to stop it making a noise. So ultimately, whilst the Pan-Pan was the incorrect DSC, it served the same purpose in alerting vessels transiting the area to the situation and to the need, from us, to get assistance, or to look for vessels in that area.
Q. Is the alert for distress slightly different to Pan-Pan, or is it the same noise?
A. It’s a different noise, but it is still an audible alarm that would need manual interaction.
Q. Do you recall who compiled the text of the Mayday Relay?
A. I don’t.
Q. Would it have been Neal Gibson, or — you don’t recall?
A. I don’t recall.
Q. And when — the text was, essentially, that the vessel was taking on water and in need of immediate assistance.
A. Yes.
Q. What did you understand the — “taking on water” to mean? Did you understand it was sinking, or …?
A. I didn’t take it to understand anything. If they have told us they are taking on water, then that is why it will have been put in there.
Q. And in terms of the vessels that responded, I understand that channel 16 was being operated by the JRCC —
A. That’s correct.
Q. — that night. So they would have taken the calls from any passing vessels that responded?
A. They would have received VHF comms from those passing vessels, yes.
Q. And who decided what to respond to any passing vessels that replied to the Mayday Relay?
A. So, it would have been Neal, if a vessel had offered itself to — to get a — to move into that area, then Neal, but that area is extremely busy and there are — you know, it’s a VTS area with deep water channels and ships would often find it difficult to deviate from courses, etc, without going against the flow of traffic which could then potentially create another incident. So, as the SMC — the SMC would make the decision about whether the vessel was appropriate. For example, you wouldn’t want an oil tanker responding to a Mayday Relay off beach at Bournemouth because you would then put that vessel and members of the public in danger. Whereas, a small leisure craft, with a small draught, if they responded and they — they would be a more appropriate asset. But in this instance, yes, it would be the SMC.
Q. Would you have expected the Maritime Tactical Commander to have been made aware of the Mayday Relay?
A. Mayday Relay is a normal tool that we use in everyday search and rescue. And no, I wouldn’t expect anyone to call him directly and say: we have issued a Mayday. No.
Q. What about if there are reports of a vessel sinking and potentially people in the water, would that have been something which might have warranted a call to the Maritime Tactical Commander?
A. No. We deal with boats all across the country every day taking on water.
Q. And just to finish that off, Dominic Golden who was the Aviation Tactical Commander on the night has told the Inquiry that nobody at the ARCC — which I think is in the JRCC —
A. That’s correct.
Q. — was aware of the Mayday Relay. Again, would this have been relevant information for the ARCC to know?
A. When — the ARCC are the tasking authority and they would hand the aircraft to us, virtually, when they take off and the taskings would be passed to the aircraft directly. The ARCC may be made aware by — may be made aware by the pilot or the crew on board the aircraft and in this instance, we are using two separate systems at that time, so they wouldn’t have seen it. But other than the need to know about timings and how long they are in the air, etc, for refuelling and replenishment and stuff like that, they would — they would keep tabs on the aircraft, but the tasking would be given by the SMC or the MRCC that requested it.
Q. So are you saying that it wouldn’t have been relevant information for the ARCC?
A. In the initial stage, no. I mean, it would be probably helpful for them further on, in terms of organising other aircraft that may need to come in and do a search and arranging all of those things. But in the initial instance, they are out on a search and resistance tasking, so they have a rescue call sign. Therefore, they are flying on a rescue call sign and that hasn’t changed what they are doing. They are just doing a specific task rather than investigating and looking for targets, which is the initial tasking.
Q. Would you expect them to be told at some point, even if not initially?
A. Yes, yes.
Q. Now, the Mayday Relay was, as we know, terminated once Valiant had arrived in the area of the Mayday Relay position.
A. Mm-hm.
Q. And this was before the Valiant was alongside any vessel; it had spotted two, but before it embarked or got alongside any of them. And you record in the Charlie log that you had had a discussion with SMC, Neal Gibson, and it was decided to terminate the Mayday Relay as — there was no requirement because Valiant was in the area investigating targets. Can you explain why that decision was made before Valiant had actually located, or been alongside, any of the small boats?
A. I don’t recall the conversation and that would be for Neal to answer.
Q. Okay. Well, let’s move to the end of your shift, then. And let’s look at your statement again. So, this is {INQ010140/18}, paragraph 50, please. And, first line, you say that at the end of your shift, you understood that the outcome of Incident Charlie was that the incident had been resolved.
A. (Nods).
Q. You knew the Valiant had arrived on scene of the Mayday Relay.
A. Mm-hm.
Q. The Mayday Relay had been stopped as a result, you knew that. We know that you entered the M number for the first small boat embarked by the Valiant, M957, against Charlie.
A. Mm-hm.
Q. Were these factors the basis for your belief that Incident Charlie had been resolved?
A. That’s correct.
Q. And the final sentence there, of paragraph 50, you say that you believed Charlie was resolved at the end of the shift because the tracker had turned green.
A. Mm-hm.
Q. I just want to look at the tracker from the end of your shift. So this is the 06:47 tracker, the last tracker before you finished, {INQ006817/1}, please. This is SharePoint number 1.235. It will just take a minute for it to come up. I just show this because this still shows Charlie as red, or as “O” for ongoing.
A. Mm-hm.
Q. Would you agree then that, at the end of your shift, Charlie was still red?
A. If that’s what the record shows, that’s correct. But —
Q. So —
A. Sorry.
Q. No, go ahead.
A. You carry on.
Q. Just to finish off, then, it probably wasn’t the tracker that gave you the feeling or the knowledge that Charlie was resolved?
A. No, no, and that may have been a mistake on my part in terms of remembering —
Q. Yes, of course. It was a long time ago.
A. — three of four — a long time ago. But it’s important to note my involvement at that point was minimal and my interest in taking the screenshot and in the outcome of these incidents was the welfare of our team. At the time, dover primarily focused on small boats and therefore, the MOOs at the JRCC and Humber had rarely got involved at that point with small boats. And therefore, when they were exposed to it, it’s important, as a team leader, I viewed, to make sure that I am informed or aware of the outcome so that I can support them. Because as I have said, the calls that people receive are fairly traumatic and repeated hundreds of times over many, many years, it gets to you. And part of my pastoral role was to make sure that people are learning, you know, from what we are doing. And it’s — that is the only interest — I don’t mean it like that. I mean the only reason I was looking was because I wanted to inform my staff and — for their welfare.
Q. Yes, and we have seen how after about 05:20, you turned your attention away from Dover. Did you ever hear directly from Neal Gibson about the outcome of Incident Charlie?
A. No.
Q. Would you have expected to?
A. No. He was busy on shift doing things. Maybe we would have caught up the next night shift, if we were both on at the same time. But no, I wouldn’t.
Q. And I think you have told us already that at the stage the Mayday Relay was broadcast, Charlie could have been one of those nine out of 10 that was exaggerating?
A. Yes.
Q. Is that how you ended your shift as well, you thought it was probably an exaggerated case?
A. I think my view was that they had been rescued. I don’t — we don’t ponder on things like that. There is no blame pushed towards people for making exaggerated claims. They do what they feel they need to do and what they are instructed to do by, from my belief, organised crime. Ultimately, I want to make sure that we are aware that people have been saved and got somewhere safe.
Q. Yes. We can take down the tracker now, please. Just finally, then, a word about what has happened since November 2021. You have obviously remained with HM Coastguard. You have been promoted to Maritime Tactical Commander, which is your current role. Are you still involved at all with small boat search and rescue?
A. Yes, I am.
Q. And are you aware of changes to any search and rescue procedures as a result of lessons learnt from the events —
A. Yes.
Q. — in question?
A. Yes. We have had — you know, small boats is ever-evolving, even now, and the steps that have been taken are significant. Things like the language barrier that we really struggle with, we have now got new tools and new software that allow us to send messages in multiple languages and it can detect the languages, which also gives us better positioning for those vessels, so that that element of it is somewhat taken away. It allows us to communicate with them via live video, if needs be, to give us a real insight into what’s going on. Likewise, training has increased significantly and has been rolled out, essentially, network-wide. Awareness of small boats and SOPs have increased and the staff that — you know, all staff are much more aware of what happens and how to respond to vessels in need. Yes.
MS MOFFATT: Thank you, Mr Barnett. I don’t have any further questions for you. Sir, I don’t know if you do?
SIR ROSS CRANSTON: No. Thank you very much, Mr Barnett. Thanks for your statement and also the evidence this morning. It’s been very valuable, so thank you. Look, it’s a quarter to 1. I think we might take our break, but coming back at 1.30 pm, would that be difficult for you? MR MAXWELL-SCOTT: I doubt it.
SIR ROSS CRANSTON: Okay.
MS LE FEVRE: Sir, can I suggest for the stenographers, we might take the full hour, but resume at 1.45 pm.
SIR ROSS CRANSTON: Right, okay. 1.45 pm. Thanks very much. (12.46 pm) (The Lunch Break) (1.45 pm)
SIR ROSS CRANSTON: Yes, good afternoon, Mr Crane. In a moment, Rekka Hollos of counsel will ask you some questions, but first of all could you just read the affirmation.
MR JAMES CRANE (affirmed)
SIR ROSS CRANSTON: Thank you very much.
Questions by MS HOLLOS
MS HOLLOS: Could you give the Inquiry your full name, please.
A. Yes, my full name is James Owen Crane.
Q. Mr Crane, you have made a witness statement that you signed on 19 November 2024 which runs to 41 pages, is that right?
A. That’s correct, yes.
Q. Now, I understand from your statement that you have been employed at the Dover MRCC for nearly 10 years now starting in November 2015, is that right?
A. That’s correct, yes.
Q. You qualified as a maritime operations operator, or MOO, in the May of 2016?
A. Yes.
Q. And a senior maritime operations operator, or SMOO, in the January of 2019?
A. Yes.
Q. You went on to complete your assessment as an SMC, qualifying into that role in the September of 2020?
A. Yes.
Q. And you then became a team leader in April 2021?
A. That’s correct, yes.
Q. Are you still qualified as an SMC?
A. I am, yes.
Q. And are you still a team leader at the Dover MRCC?
A. Yes, I am.
Q. And I think at the time of the events in November 2021 you were the team leader of team 4, is that right?
A. Yes, team 4.
Q. Thank you. As at November 2021, had you received all the training considered necessary and appropriate from His Majesty’s Coastguard for carrying out your role as an SMC and a team leader?
A. I believe so, yes.
Q. You have outlined in your witness statement for us the training that you have received. Can I just check, the Inquiry has seen evidence of some training slides from presentations in the June of 2021 and the August of 2021 relating to migrant incidents phases of response and confirmation bias and human factors. Did you attend one or both of those training sessions?
A. I would have been shown them as they came out, yes.
Q. Did you find that training helpful in carrying out search and rescue operations involving small boats?
A. Yes. The situation regarding small boat crossings was a rapidly evolving situation, so a lot of the training that we did at the time leading up to those presentations coming out was done as it was — as the jobs were increasing and then these presentations were brought out to further the operators at Dover, their knowledge, to expand that to the wider national network of HM Coastguard.
Q. Thank you. Now, you have mentioned the increase in the small boat crossings already. In the November of 2021, or by that stage certainly, do you recall how frequently you were dealing with significant small boat activity during a shift?
A. Have you been made aware of the weather forecasting —
Q. Yes.
A. Okay. So with those weather forecastings, with the red amber green forecast, with the amber and red days we knew that we were facing largely increasing numbers, and certainly on the red forecast days we would have significant workload in the Dover operations room and other stations taking the overspill calls from persons crossing the Channel in small boats. So for an amber and a red day it wasn’t uncommon for us to have a significant increase in our calls for the day.
Q. What was the impact of those increases in small boat activity on your work, as far as you were concerned?
A. It meant that as an SMC I am meant to have the oversight of incidents and be able to co-ordinate a number of incidents at once. When it came to small boat crossings the amount of incidents that we had — sorry, the amount of calls, sorry, that we had coming in meant that it was very difficult to keep up, as an SMC, with that call demand and the workload in order to successfully manage my team during the day-to-day operations.
Q. I would like to come, please, on to the calls that were coming in from persons on small boats. You tell us in your witness statement, and we have heard evidence from other witnesses to this effect as well, that you were aware of increasingly exaggerated levels of distress being reported by callers from small boats. How often did you find that to be an occurrence?
A. Almost all the time. It’s — it seemed to us that those persons that were crossing the Channel were given a script to say to the coastguard or UK emergency services in the belief that if they said that their numbers on board were higher or that the injuries to the persons on board were significant then it would get them a faster response than had it been for a smaller number and no injuries to anyone on board.
Q. How, if at all, did your experience that some of these calls were exaggerating the levels of distress affect the search and rescue response?
A. The nature of the calls coming in and the information that we were getting, it was very difficult to try and work out and process what was a genuine reflection for what was on those vessels as opposed to any exaggerated numbers which may have been coming from those persons on board. And certainly with language barriers, the use of interpreter services, it was used by us to try and get further information from those persons on board. But largely when we were trying to connect the interpreters to get that information, the person that we were talking to would put the phone down on us. We weren’t always able to clarify exactly what was going on. And this is still something that we face to this day with persons crossing the Channel.
Q. Faced with what you have described as the difficulty between distinguishing whether the levels of distress were genuine or exaggerated, how did that affect how would you then respond to the incident?
A. We had to take every call as it came and, and grade it and classify as we saw fit.
Q. In circumstances where you were responding to multiple small boat incidents simultaneously, did the levels of distress reported by the callers factor into prioritising which small boat response came first?
A. The way that we responded to them at the time was that the one that was either closest to or into UK search and rescue region or the UK waters, they were the ones that we would collect first. If there were any that were found to be in French waters, they were reporting any distress, we would liaise with CROSS Gris-Nez, who are the French coastguard, and we would pass them that information to say this is in your territorial waters, we are dealing with incidents in our own waters, but we have found out through various positioning ways through WhatsApp and live locations, which is the most common one that we used, and we would pass that to the French and say can you respond to this one.
Q. So would it be fair to say that it was the geographical location of the small boat that had the biggest role to play in determining which small boat incident was being responded to first?
A. Initially, but if we had any aerial surveillance that could prove that a vessel was in significant distress, then that vessel would take the priority over the ones that were in UK waters.
Q. Thank you. I would like to ask you, please, about the standalone mobile phone in the Dover operations room. Do you know what I am referring to?
A. Yes, I do.
Q. Now, in your statement you describe that mobile phone as being: “… for us to use WhatsApp to converse with those persons making the crossing and for them to share their live location with us.”
A. That’s correct, yes.
Q. When you refer to conversing with persons making the crossing, what types of communication were you expecting to use the mobile phone for?
A. So if we could get a phone number from the vessels coming across the Channel, we would put that number into the standalone mobile, we would send them a WhatsApp message asking them to share their live location, and if they were making any calls into the mobile we would advise them to dial 999 and ask for the coastguard so then it came through our recorded phone lines 999.
Q. And that, that instruction that if the calls were made to the standalone mobile phone the caller would be advised to dial 999 instead, was that part of any training or guidance or instruction you had as at November 2021 about how the mobile phone was to be used?
A. I don’t recall a specific instruction at that time.
Q. That deals with calls being made to the mobile phone. What about if there were follow-up WhatsApps, so not just relating to the geographical position of the caller of the small boat, but follow-up messages into the standalone mobile phone? What was your expectation as to how those messages would be dealt with?
A. So those messages, if we could link it to a telephone number that we had already got a coastguard incident open for, we would — I would detail one of my team to transcribe that message from the WhatsApp message on that phone directly into the incident itself and note in their entry into the incident that this has come from the WhatsApp message on the phone.
Q. And when you say entry of the incident do you mean the incident logon ViSION?
A. Yes.
Q. In terms of detailing your team, is that a specific role or task that you assign to them at the outset of your shift, or was it more on a responsive reactive basis?
A. No, as my role as team leader, I would detail roles to members of my team when I came on shift that morning.
Q. So does it follow that dealing with the mobile phone was one of the roles that you detailed to your team —
A. Yes.
Q. — at the beginning of your shift?
A. (Nods)
Q. And was that always the case?
A. If we were experiencing small boat crossings, then yes.
Q. I would like to ask you please next about the shared tracker, or I think what you refer to as the small boat tracker in your witness statement.
A. Okay.
Q. You tell us in your statement that it was known as the shared tracker because Border Force also had access to it?
A. That’s correct.
Q. In terms of access, was Border Force able to edit or amend the shared tracker, or simply to view it?
A. Border Force had got access to it to make amendments to it and the arrangement that we had with them was that coastguard would deal with all of the positioning information, the assets that were assigned and the initial reported numbers, and then Border Force would deal with the recovered numbers as they were talking directly to their assets out at sea.
Q. When do you think, or when can you recall Border Force were first given access to be able to amend that tracker?
A. I can’t remember that, I’m afraid.
Q. Do you remember whether it was before or after the 24 November 2021?
A. I believe it was before.
Q. Pushing my luck too far to ask you how far before?
A. I’m sorry.
Q. That’s quite all right. You have told us that there was an arrangement as to who would complete which portions of the tracker, and I think it would be helpful for us to bring up a version of it so you can talk us through it, please.
A. Okay.
Q. Can we have {INQ006814/1} up on screen, and this is the native file so it will just take us a second to bring it up.
A. Okay.
Q. So that I can orient you, this is a version from 24 November 2021 with the last change date at 06.35 by Neal Gibson. Now, you have told us that the arrangement was for Border Force to enter the recovered numbers, and if we can just scroll along, please, all the way along. Thank you. Just there, perfect. “Actual number recovered (per vessel)” we can see in column T, is that where you are expecting Border Force to complete the number of persons recovered from vessels?
A. Yes, I would. So as you look at the top rows, rows 3 and 4.
Q. Yes.
A. So anything that was in yellow would be for coastguard; anything in black or grey would be for Border Force.
Q. And if we could scroll back along, please, to the first set of columns to column A. Thank you. Now, one of the headings under column G is “UK Border Force reference”, and the example is given of an example Mike number, as we have been referring to.
A. Yes.
Q. Now, this falls in your example as a yellow column, so something that you would be expecting the coastguard to fill in, is that right?
A. That’s correct, yes. The M number would not be normally assigned a crossing reference until the Border Force vessel had sight of it and were making their approach to it. We would then get the reference from Border Force and then we would put it into the tracker and the ViSION log.
Q. As it was a Border Force reference that needed to be input into that column, was the expectation not that Border Force would enter it?
A. Sometimes they would to help us out if we were busy. It’s just, again, dependent on the workload that was going on in the room at the time.
Q. This arrangement that you have described, that the coastguard completes the yellow-headed columns and Border Force completes the grey, was that recorded in any written guidance, instruction, policy, operating procedure, anything along those lines?
A. I don’t recall, sorry.
Q. Do you recall how you first became aware that this is going to be the arrangement, we are going to complete this section, Border Force will complete that section?
A. I believe it might have come from an email from my one of my staff officers, but I can’t be 100% certain on that, I’m afraid.
Q. Thank you. Could we take that down, please. I would like to ask you then about an email in which you, which you sent to George Papadopoulos on 26 November 2021 in which you discuss the use of the shared tracker. Could we please have {INQ003735/2} on the screen. As you say, this is an email sent by you to George Papadopoulos who was, I think, the small boats Tactical Commander?
A. That’s correct, yes.
Q. And you send it on 26 November and the subject is observations from the 24 November.
A. Yes.
Q. Which is when you were working a day watch, I think?
A. That’s correct.
Q. We will come on to the events of that watch in due course. Could I go overleaf, please, to page 3 {INQ003735/3}. And then if we could go into the paragraph headed number 3. Can you see there you raise the concern that the Home Office now have access to the shared migrant tracker. You set out your understanding that they would be filling in statistics and numbers for us. Just pausing there for a moment. Statistics and numbers. Are you referring there to the columns on the shared tracker you have just talked us through?
A. Yes.
Q. Now, you go on to say this was not done. I assume you mean in relation to the day of the 24th?
A. That’s correct, yes.
Q. And they left us asking questions about M numbers and incident feedback as well as final numbers. What were the difficulties if Border Force didn’t fill out those sections of the tracker?
A. It was really just to — the expected numbers of persons that were involved during that day. When we had some of the Border Force boats that were picking up the small boat crossings, we would get a breakdown of numbers for them or they would speak to our Border Force colleagues for that as well as speaking to us on our operational channels. And it was our understanding at the time that Border Force would fill in the end columns which we could then tie back to the ViSION incidents and get a count of persons assisted during the day. And with that not happening it was leaving us asking more questions of who’s got what, what are the numbers, how many have we picked up, how many are we still expecting.
Q. So is it linked then to your ability in the operations room to reconcile the boats that had been embarked or had been picked up —
A. Yes.
Q. — with the ongoing incidents you had on ViSION?
A. Yes.
Q. Thank you. We can take that down now, thank you. I would like to come, please, to the topic of handovers. In your witness statement you tell us that shifts at Dover MRCC are 12 hours, running from 7.30 in the morning to 7.30 in the evening for the day shift and the reverse for the night shift?
A. That’s correct.
Q. Now, your normal shift pattern you describe in your witness statement was 4 on, 4 off?
A. Yes.
Q. Mr Gibson told the Inquiry in his evidence last week that due to low staffing levels he was frequently working a 6 on, 2 off shift pattern in November 2021. Did you experience any similar alteration to your regular shift pattern due to low staffing levels at the MRCC?
A. No. So the pattern that Mr Gibson would have worked was a voluntary method that he opted to do simply because he — he lives the closest to the station. Where I live, I am one of the persons that lives the furthest away from the Dover station. So the pattern that Neal was doing of the 6 on, 2 off wasn’t — wasn’t suitable for me.
Q. Understood. Coming, then, on to handovers. You tell us that you receive a handover at the beginning of every shift —
A. Yes.
Q. — from the outgoing watch. And you tell us that in particular, there are two documents that tend to be used for that?
A. That’s correct.
Q. A PowerPoint and a small boat crossing briefing document?
A. That’s correct.
Q. In terms of the small boat crossing briefing document, is that a live document that gets updated in the same way as the PowerPoint for the handover does?
A. Yes. Both documents are handovers which are stored as live documents, so they will be updated throughout the day or the night.
Q. And what information is contained in the small boat crossing briefing document?
A. So it would cover any of what we call the “fly pro”, so any flying programme that’s going on for coastguards or any other asset. The weather forecast, which would lead us to understanding if we were expecting any crossings, any ongoing incidents. Anything of note surrounding any of the surface assets. So if any of the Border Force vessels are on a limited capability for any reason. And then just any other business that we could associate to anything which was small boat-related.
Q. In terms of ongoing incidents, are we there referring to anything that hasn’t been marked as closed on ViSION?
A. That’s correct.
Q. And in terms of the level of detail that you would receive in relation to an ongoing incident in that briefing document, help us with how much information you would get.
A. It would be very brief. So, for instance, it would be: Event Alpha, Border Force asset assigned, a rough location and any French asset that is on scene with it. And then we’d then move on to the next one. So it’s bare minimum information to give someone an overview, and if they want more information they will then go into the incident and read through in greater detail. But for the purposes of handover, of giving what I needed to to either the on or the ongoing watch — on or offgoing watch, sorry, it’s just a quick snapshot of what’s going on at that time.
Q. Thank you. I would like to come, please, to the events then of your watch on 24 November when you were working I think the day shift from 7.30 to 7.30.
A. Yes.
Q. Now, were you based in the operations room at Dover?
A. Yes, I was.
Q. And you were SMC and team leader that day?
A. Yes.
Q. In terms of your team you tell us at paragraph 34 of your statement — and if we could just have that up on the screen, please, thank you {INQ010142/13} — that your team consisted of three SMOOs, one qualified MOO, one trainee MOO and a member of staff from the JRCC.
A. That’s correct, yes.
Q. In terms of the trainee MOO, they hadn’t completed their communications ticket, as it were, is that right?
A. At that time, no.
Q. So they were not operational?
A. No.
Q. Does that mean that if they hadn’t completed their communications ticket and they were not operational, they weren’t able to do things like to make telephone calls to any search and rescue partners?
A. What we did at the time was that in order to get the trainee MOO proficient with phone calls, there were certain calls that we would allow them to speak to, and the role of that trainee MOO was they would be the one that I would assign the standalone mobile to so that they could keep an eye on any messages coming in and out from there, as well as the small boat crossing inbox that we use for our external partners, so that they could input the information into incidents as the calls were coming in and out — sorry, not calls, the messages and emails were coming in and out on either that standalone phone or the inbox.
Q. So their function was to take the contents of the inbox or take the content of the messages on the mobile phone and ensure that they were appropriately logged in the incident logs?
A. Yes. And from what I remember on the day, the trainee MOO was sat next to the qualified MOO, so they were working together.
Q. In terms of making any proactive calls to search and rescue partners, was that something they were permitted to do?
A. No, they weren’t.
Q. If a call came into the standalone mobile phone, would the trainee MOO be permitted to pick that up?
A. Yes, with the instruction that I mentioned earlier about the need to call 999 and ask for the coastguard. At which point if the call came across on 999, one of the qualified members of staff would pick it up.
Q. Thank. You. Now, by my count that takes us to six staff members, seven including yourself. But I think overleaf on paragraph 35 in your statement, {INQ010142/14} you describe there were eight members of staff on your team that day. Who was the eighth, or what role did they play?
A. That would be George Papadopoulos who was in acting as the small boat commander.
Q. I see. So you are counting Mr Papadopoulos as part of the eight in the team that day?
A. Yes, I am. I think it is important for me to mention though that I mentioned I had three SMOOs in there. They were the VTSOs, or the Vessel Traffic Service operators; they have got no access to the ViSION systems or any of the 999 calls coming in. So although I am counting them in my numbers, they had no active search and rescue role on the day.
Q. So if we take those three out, that leaves for search and rescue-related response five including yourself, one of whom was a trainee?
A. That’s correct.
Q. Do you think that number of staff, so five including a trainee, was sufficient in your view to maintain operational control of small boat crossings that day?
A. On that day with the number of calls that were coming in at that time, looking back in hindsight on it I would say no. But at the time that’s what we were used to working with, and so that — that was what I was used to, that was what I ran with.
Q. Does it follow, then, that there were other shifts when you felt actually the number of staff we have working search and rescue in light of the amount of small boat crossings just isn’t enough?
A. At times, yes.
Q. How frequently did you feel that in the November of 2021?
A. I don’t recall, I’m afraid.
Q. We can take the statement off the screen, please. Thank you. Now, at the outset of your shift on 24 November you tell us that you received a handover from the outgoing SMC, Neal Gibson.
A. Yes.
Q. What do you remember about the contents of that handover?
A. I don’t remember a huge amount about it. I remember him saying that it had been a busy night, and I was aware that whilst I was receiving the handover from Neal that calls were still coming into the operations room. He would have covered the open incidents as best that he could, he would have advised me that there were some incidents which had been completed and others which would have been identified as repeat incidents and merged into the already open incidents as necessary. But as for the specifics of what Neal discussed with me, I can’t remember exactly what he said on — on that morning.
Q. Can I ask you about one aspect of the handover that you do mention in your witness statement. And if we could have paragraphs 41 and 42 from page 15 up, please, {INQ010142/15}. In fact, actually overleaf, please, {INQ010142/16}. The next page, please. Yes, lovely, thank you very much. Paragraph 43. One of the aspects of the handover that you do mention is the fact that there had been a Mayday Relay broadcast in relation to a small boat incident. In your experience, was that a usual or an unusual event to have happened in relation to a small boat crossing?
A. It was — it was actually slightly unusual — sorry, it was usual because part of our SOPs and guidance was that we were supposed to do Mayday Relay broadcasts for any and all small boat crossings in the Channel. So for Neal to say that he had done a Mayday Relay broadcast, whilst it would have normally been unusual for small boats it was fairly common.
Q. How frequently in shifts that you had either been there yourself or had had handed over to you, were you made aware of a Mayday Relay broadcast being made in relation to a small boat crossing?
A. If it was going on at the time, then yes, we would have carried that on. Unfortunately, due to the amount of workload that we were dealing with with the number of calls coming in, quite often this SOP wasn’t followed and we were not able to do Mayday Relay broadcasts on every single small boat incident.
Q. So how frequently do you think Mayday broadcasts were issued in relation to small boat incidents?
A. Not as frequently as they should have been.
Q. Every shift? Every other shift? Once every month? Any further specifics you can give us?
A. Every other shift, probably.
Q. You have mentioned that it was actually formally part of the SOPs to issue a Mayday Relay broadcast in relation to small boat crossings?
A. Yes.
Q. Do you recall which SOP that was contained in?
A. Not off the top of my head, no. I believe it might be the one relating specifically to incidents for migrant crossings.
Q. And to the best of your recollection, was that incorporated in the SOP prior to 24 November 2021?
A. I can’t be certain of that, I’m afraid.
Q. All right. In terms of the handover, Mr Gibson, you tell us, advised you that there had been a Mayday Relay broadcast in relation to an incident. Having been informed of that fact, would you look at what the text of the Mayday Relay actually was?
A. I would have done, yes.
Q. Do you recall whether you did so in fact on this occasion?
A. I can’t be certain, I’m afraid. As I say, with the amount of calls that were still coming in I –I am not sure if I acknowledged the handover, sat down and started picking up calls, or whether I went through the open incidents. I don’t recall that, I’m afraid.
Q. When you did look at the context of a Mayday broadcast what was the purpose of you doing so?
A. To understand what Neal had done during the night.
Q. Now, you mention that as part of your handover you are aware that it was an extremely busy night shift and staff hadn’t been able to take their breaks and that there was a high level of calls coming in. At that stage, did you consider seeking any additional support from within the network to try to ease the burden on your incoming watch?
A. I believe at that time that support had already been gathered from the national network, and the functions for the two northern search and rescue zones, zone 11 and zone 13, which covers from Felixstowe down to Ramsgate, they had already been passed to other stations, as well as the channel 16 operator was at the JRCC. So at that point we had done everything that we could to reduce the workload in the Dover ops room by utilising the national network.
Q. Thank you. We can take the statement off the screen, please. Thank you. So that’s dealt with human resources available to you and within the room. In terms of assets and in particular in terms of surface assets available for tasking during your watch, you tell us in your statement that at the beginning of the shift you had available to you a cutter, a coastal patrol vessel and a crew transfer vessel?
A. That’s correct, yes.
Q. Did all three vessels remain available for tasking throughout your watch?
A. No, they didn’t.
Q. What happened?
A. So the cutter, the Valiant, suffered an engine problem and had to return to Ramsgate, leaving me only the coastal patrol vessel and the crew transfer vessel.
Q. And in your view, those two vessels, was that a sufficient number of surface assets for you to maintain operational control over the Dover Strait?
A. With the amount of calls coming in and the crossings we had, no, it wasn’t.
Q. Can we have up, please, {INQ003735/2}. Now, again, this is the email that you sent to George Papadopoulos and one of the concerns that you raise is precisely around this issue about the availability of assets from Border Force on the day of 24 November. And one of the things that you identify is the need for more Border Force officers to be trained in boat handling and for deck crews to ensure there is adequate coverage for a 24-hour period. Why is it that you thought it was more Border Force officers that were required?
A. Because the Border Force crews, certainly on the CTV, the crew transfer vessels, those vessels are contracted to Border Force. So you have a commercial crew and a Border Force crew that are both on board. The commercial crew would be in for their contracts, because I believe we brought the vessels from the wind farms. But it was the training of Border Force officers to crew those CTVs which was causing us the lack of assets.
Q. Sitting here now in March of 2025, do you still have concerns about the sufficiency of Border Force assets to respond to the volume of small boat crossings?
A. No, I don’t.
Q. What has changed?
A. We have now got five crew transfer vessels which are fully staffed by Border Force and contract crews, and they are now on a rotation to ensure that there is always one if not two Border Force boats that are always available during expected crossing days. And when we have the amber and the red days, there are more surface assets that are available to us.
Q. Insofar as the air assets were concerned — we can take that off the screen, thank you — you explain in your statement that you had available to you two assigned fixed-wing assets during the watch, a King Air and a Panther?
A. That’s correct, yes.
Q. Were both of those air assets available to be tasked during your watch?
A. No.
Q. What happened there?
A. So both of those aircraft were based at Humberside Airport, I believe under the call signs coastguard 25 and coastguard 26. The first asset to come down, coastguard 25, had a technical issue whilst they were lining up on the runway and had to return back to the hangar. The crew then transferred into coastguard 26, which added a delay in them coming down to the Channel to perform their patrols. Whilst they were up, the crew of 26 reported that they needed to go into Southend Airport for refuel, and whilst they were there that aircraft also developed a fault. And by the time the fault was rectified, the crew were out of hours and had to return back to Humberside. So it meant that the two coastguard assets that I had for the day, I only had about 20 or 30 minutes of one of them being on scene.
Q. Understood. Now, in that same email to George Papadopoulos that we have just been looking at — and if we could have it back up, please, thank you very much, {INQ003735/2} — another of the concerns that you identify is the lack of communication from ARCC to Dover MRCC about the late departure of the aircraft from Doncaster. In your experience, were delayed updates about the status of aerial assets a usual or an unusual occurrence as at November 2021?
A. That would have been unusual, because normally the air rescue centre are very good at passing on any delays from aerial assets to the MRCCs because of the search and rescue nature of the work that it is that we do.
Q. Thank you. We can have that off the screen. Now, you have mentioned that your two aerial assets effectively went down to one. What was the effect of that lack of coverage from 2Excel on your ability to maintain operational control over the Dover Strait?
A. It just meant that without the aircraft being in the skies above the English Channel, that I couldn’t maintain the operational oversight of the crossings that we knew were coming over, the numbers of the reports that we were receiving at the MRCC. And it meant that I couldn’t link calls to incidents to say that there was a specific number of vessels in a location or give any oversight to where I could preplan to put either a Border Force asset or anything else that could be available to me at the time.
Q. Is there anything that you could do to mitigate that loss of situational awareness?
A. Yes, I could have spoken to the air rescue centre and requested a rotary wing and use our search and rescue helicopter from Lydd. The drawbacks to that is it doesn’t fly as high or as fast as the fixed-wing, so I couldn’t have covered the entire area at the same pace that the fixed-wing could. Also, I know that Home Office were utilising aircraft as well, but our contact to them was very limited at that time.
Q. All right. I would like to come on to a little bit later during your day watch, and in particular to an incident that you dealt with called incident X-ray 2.
A. (Nods)
Q. Now, if we could have up your witness statement please, page 25, paragraph 77 {INQ010142/25}, incident X-ray 2, you describe, was a rescue operation that came in following a call from the French coastguard. About 10 to 15 people in the water, possibly unconscious, and a request for aerial support. Is that right?
A. That’s correct, yes.
Q. Now, just pausing there. Since the incident was assigned the alphanumeric reference X-ray 2, is it right that in sort of the 13 hours of 24 November you had cycled through the alphabet nearly twice?
A. Almost three times by that point, yes. So we start with just the letter. By the time we get to Zulu, we will go to Alpha 1, get to Zulu 1, Alpha 2. So this is now the third time round the alphabet that we have been.
Q. Thank you. What was the role of HM Coastguard in responding to X-ray 2?
A. Well, we received the call from CROSS Gris-Nez, the French coastguard, and they reported to us, as is put in my statement there, which is from the call collection that the qualified MOO took. And as far as I was concerned with this incident, the French confirmed they had primacy and priority in dealing with it and I was providing them with mutual aid with use of an HM Coastguard aerial asset.
Q. And I think it’s right that in fact you also sent a Tekever drone?
A. That’s correct, yes.
Q. As well as a rotary wing?
A. Yes. So what was — my thinking there was we sent the Tekever drone over there so that the drone could hold in a mid-level orbit to get footage sent back to us so we knew what was going on, whilst the helicopter would be operating low level in assisting the French as well as — in my statement I have mentioned they have got the French rescue helicopter, Guepard Whiskey, so that is rescue GW. So the two helicopters would work together with the drone giving a visual oversight of what was going on so we could see what was happening.
Q. Thank you. We can take that off the screen. Now, we know from the ViSION incident log for Incident Charlie that it remained open on 24 November and it wasn’t closed until 21 minutes past 3 that afternoon; so about two hours or so after you had been alerted to incident X-ray 2 by the French coastguard. Would it then be fair to say that Incident Charlie was an ongoing search and rescue incident at the time X-ray 2 was opened?
A. No.
Q. Okay.
A. There was a comment in Incident Charlie from one of the network commanders on the day shift, I forget what time the entry was put in, I believe it was around 10 o’clock in the morning, stating that the information suggested that the Border Force cutter Valiant had effected a rescue of Incident Charlie during the night. So I would have seen that comment during the day, and at the time that Incident Charlie was closed by us in the afternoon, and that’s when we were catching up with the incidents that were, as far as we were concerned, finished but we hadn’t got round to closing.
Q. I see. The comment that you refer to from the network commander, is that from a Mr Close?
A. That’s correct.
Q. If we could have that up on screen briefly, please {INQ00237/13}?
A. Yes. 14:28:05 8 Q. So there is an entry at 10:08:47 from G Close: “Commander message. “Note from tracker this incident shows as resolved – Valiant tasked – confirmed 41 recovered and [vessel] abandoned and marked.” Is that the comment that you were just referring to?
A. Yes, it is.
Q. So that’s what led you to believe that the incident was resolved although it remained open on ViSION?
A. That’s correct, yes.
Q. Thank you. We can take that down from the screen. At paragraph 80 of your statement you tell us that at the time of the call from Gris-Nez in relation to X-ray 2, there was nothing to suggest this incident was in any way related to Incident Charlie. Do I take it from the answer that you have just given us that that was because you had considered Incident Charlie resolved because of the comment made by George Close at 10.08?
A. Yes, that is correct.
Q. Thank you. I would like to come, please, to then the closure of incidents on ViSION. As SMC, it’s right that you are responsible for all search and rescue operations until they are completed.
A. That’s correct, yes.
Q. Who has the final say in determining when a small boat search and rescue operation is closed on ViSION?
A. That would be me as the SMC.
Q. Can we please bring up the incident involving migrants SOP, {INQ000428/1}. And if we could go, please, to page 6 {INQ000428/6}. The box headed “Termination of [Search and Rescue] Response” sets out the circumstances in which it can be terminated, where: “Reliable and credible sources suggest the emergency no longer exists. This must be agreed by the JRCC Commander.” So before a decision can be reached you need reliable and credible sources to suggest the emergency no longer exists?
A. That’s correct, yes.
Q. Thank you. Could we please bring up the search suspension and termination SOP, {INQ000450/1} and {INQ000450/2}, please. Before a decision can be reached to suspend or terminate a search and rescue incident, you must review the incident to ensure that it has been conducted correctly. And the series of bullet points set out what that review must include, is that right?
A. That’s correct, yes.
Q. We can take that off the screen, please. You address the requirements to record reasons for closing an incident at paragraph 89 of your statement. And if we could have that up, please, it is page 29 {INQ010142/29} you say: “As set out in the SOP we should always record the reasons as to why we are closing duplicates …” Just pausing there. Should you also record the reasons why you are closing any incident, not just duplicates?
A. Yes.
Q. And you go on to say: “… unfortunately this is often not done when we are busy, as dealing with the calls takes priority over recording our reasons for closure.” As at November 2021, how common was it in your experience that a shift was so busy that there was insufficient time to record the reasons for closing an incident?
A. Quite often. On that day I know that we — we opened some 92 incidents throughout the 24-hour period of that day, which certainly with my team dealing with that, I believe there is a couple of emails that we sent to the French that are only about an hour and a quarter apart from each other, and in that hour and 10 minutes or so we opened 45 of those incidents. So the workload that we had at that point was such that — and, you know, we — we did not always follow the SOP at that time.
Q. Has that position changed or improved since November 2021?
A. Yes, it has, drastically. The number of calls that we are receiving now are far less. Because we have the greater numbers of Border Force assets, we are very rarely now having a vessel engaged in small boat crossings coming into UK waters unaccompanied by a French asset, or when we know that a French asset’s coming over we can arrange a meeting between the British and the French Border Force, Navy, to collect that vessel before it comes too far into UK waters and we start getting an excess of calls coming in. So now we have got all these in place, it means that we can follow this SOP and we can record our decisions a lot better than we did back then.
Q. Thank you. We have already discussed Incident Charlie coming to be closed at 21 minutes past 3 on the 24th. What was your involvement in the decision to close that incident?
A. Which incident, sorry?
Q. Incident Charlie.
A. So I would have taken the comment made by George Close at 10 minutes past 10, stating that the vessel had been picked up, and because that would have come from a commander, a person of a senior rank than me, I would have taken his comment that the incident was ready to close.
Q. I see. We can take the statement down, please. Now, there are a number of other incidents that were closed with the rationale expressed in identical terms, and I would just like to remind you what that was. So by way of example could we please bring up {INQ000246/1}. This is the ViSION incident log for Incident Lima, and if we could go to page 5, please. {INQ000246/5} There we have the message recorded by the trainee MOO at five minutes to 6 in the evening: “After the cessation of multiple migrant incidents during today. No further calls have been received for this incident or further confirmed sightings. Areas of interest have been searched with nothing untoward found. With this in mind, it is being closed pending further information. As discussed with James Crane and George Papadopoulos.” You accept in your statement, I think, that this closure rationale was inaccurate insofar as Incident Lima was concerned because in fact Incident Lima related to a small boat that had been embarked by the Valiant?
A. Yes.
Q. And we can take that off the screen, thank you. Now, the same wording appears for the closure of incident November and for Incident Foxtrot. Are you able to help us with why the same generic closure statement was made in all of those cases?
A. Yes. And that was a discussion that I had with George Papadopoulos. With the number of incidents that we had, we decided to use a generic closing statement. It’s not something that we would do normally and it certainly isn’t something that we do any more. It was something that I felt on the day, because of the number of calls that we had had and basing it on previous incidents from other days, a generic closing statement was utilised. I acknowledge now that that wasn’t the best practice that we should have adopted. I should have made an entry into every job specifically for that, that incident, and that is a decision which I — I do regret now by, by choosing to use a generic statement for multiple incidents.
Q. I think we first see an example of the generic statement in an email from you to various people in August of 2021. If we could bring that up, please. It is {INQ010349/2}. At the very bottom, please. So this is an email from yourself to various on 21 August 2021. Would that tend to suggest that this practice of using a generic closing statement is something that had been ongoing since at least August 2021?
A. Yes.
Q. And was that a function of the busyness of the shifts that you were dealing with?
A. Yes, it was. As I mentioned, the number of calls that we had coming in and the number of open incidents that we had, that’s why I chose to use a generic statement. And in my previous answer I said it’s not something that we do anymore.
Q. Thank you. When did that stop being a practice?
A. I don’t specifically recall, but it would have been after this incident.
Q. Other than yourself, are you aware of any other SMCs also making use of generic closing statements?
A. I don’t know, I’m afraid.
Q. We can take that down, thank you. Do you think there was a risk with issuing that instruction of a generic closing statement that incidents would be closed collectively rather than by undertaking an individual review of the circumstances?
A. Yes.
Q. Do you think that’s a possible explanation for why the inaccurate rationale was recorded for at least Incidents Lima, November and Foxtrot?
A. Yes, I do. And if it was made by the trainee MOO, that is something that I should have kept an eye on rather than letting him put multiple statements into multiple incidents, as identified, incorrectly.
Q. Thank you. I have just one final topic, please, and I’m afraid it is a return to the Mayday Relay broadcast, if I may.
A. Okay.
Q. Earlier you told us that you believe it was part of the existing SOPs at the time to issue a Mayday Relay broadcast in relation to small boat crossings, but that quite frequently that didn’t happen because there was insufficient time to do so. Can I just please bring up {INQ00428/1}. Now, this is the incident involving migrants SOP that we have already looked at briefly, but I would just like to come on to page 4 of that document, please. {INQ00428/4} Now, this refers to broadcast action. Is a broadcast action different to a Mayday Relay broadcast?
A. Yes. So the Mayday Relay broadcast, so Mayday is a recognised distress proword, which would request information or action from any passing mariner. Whereas this broadcast which is on the screen in front of me is an information broadcast. So it’s to make people aware there is something going on, but I don’t require them necessarily to take any action unless it’s stated in there, which this broadcast at the bottom there reads: “Anyone with information on such activity please report to UK Coastguard via the usual methods.” Whether that be via 999 or on VHF.
Q. Now, this is the investigation of the SOP that was in force in the November of 2021, and we have not been able to find reference in it to a Mayday Relay broadcast being a recommended course of action in relation to small boat crossing. Is it possible that your recollection that the Mayday Relay broadcast, as opposed to a broadcast action, was included in the SOP is mistaken?
A. More than probably, yes.
MS HOLLOS: Thank you very much. I don’t have any further questions. Sir, do you have any questions? Questions by SIR ROSS CRANSTON
SIR ROSS CRANSTON: Can I just ask about the Mayday Relay, as in the purpose. The evidence we got this morning I think was that it was used on at least one occasion to obtain situational awareness. Is that the purpose?
A. It’s one of the purposes. We can request information from a scene or we can request anyone with a certain capability to assist. So in this case with small boat crossings, it would be we are questioning anyone with information who might know of something going on in an area to respond with information. Or if there is a specific known problem with an incident, which now we know with Incident Charlie we had multiple persons in the water, anyone who is able to assist in the recovery of these persons. The Mayday Relay can be tailored to a number of different circumstances. It is largely a free format message that we fill in the details as required in the incident that it’s being broadcast for.
SIR ROSS CRANSTON: Well, that’s very helpful. There is nothing more on that.
MS HOLLOS: No, thank you.
SIR ROSS CRANSTON: Thank you. Well, thank you very much, Mr Crane. Thanks very much for the statement and also the evidence this afternoon. It’s been very helpful.
A. Thank you, sir.
SIR ROSS CRANSTON: So I think we will have a 10-minute pause and then I think we have got Mr Jones. Yes. (2.42 pm) (A short break) (2.52 pm)
SIR ROSS CRANSTON: Yes, good afternoon, Mr Jones. I know you have been here since earlier this morning and it’s taken a bit longer than expected, but it’s good to have you here finally. Could you please read the affirmation.
MR DAVID JONES (affirmed)
SIR ROSS CRANSTON: Now, Ms Meredith of counsel is going to ask you some questions.
Questions by MS MEREDITH
MS MEREDITH: Please give the Inquiry your full name.
A. David Jones.
Q. You have prepared a witness statement for the Inquiry dated 18 November 2024, which is 23 pages long.
A. That’s correct.
Q. You explain in your statement that in November 2021 you were employed by Her Majesty’s Coastguard, which was part of the Marine and Coastguard Agency or the MCA?
A. That’s correct.
Q. By November 2021 you had served 26 years with HM Coastguard and had been promoted to the role of maritime operations controller, which I think was later known as network commander, is that right?
A. That’s correct, yes.
Q. As part of this role you also acted as a Maritime Tactical Commander and you have now left HM Coastguard in 2022 and work for the Fire and Rescue Service?
A. That’s correct, yes.
Q. If I could ask you to bring up {INQ010138/1}. You will see in front of you your statement, and if we look at paragraph 6 onwards, you explain that in your role as a Maritime Tactical Commander, you were based in the Joint Rescue Co-ordination Centre in Fareham and that the Joint Rescue Co-ordination Centre coordinated and organised the 11 maritime rescue co-ordination centres, including by ensuring that each had adequate resources?
A. That’s correct, yes.
Q. And then at your paragraph 7 you explain your functions and responsibilities, and in particular you say your role was to have oversight of the UK national network of all 11 MRCCs, to ensure that the national network could function efficiently and effectively with the number of staff and other resources available, and to maintain an overview of raised incidents, assess risk across the network and ensure resources were distributed across the network so that functions were delivered. Is that right?
A. That’s correct, yes.
Q. If we look at page 3 of your statement at paragraph 9 {INQ010138/3}, you provide more detail, in particular explaining that you had to balance the operational and staff welfare needs, and this included ensuring MRCCs had cover in place so staff could take breaks or rotate operational roles?
A. That’s correct.
Q. And then at paragraph 10, you explain that you would also keep an overview of search and rescue mission co-ordinator plans for particular SAR responses to ensure they had appropriate plans in place and resources needed to carry out the plan, in particular by inserting a RAG, or review assess guidance, entry into an emergency incident. Is that right?
A. That’s correct, yes.
Q. How, practically speaking, would you keep an overview of the plans of the SMCs?
A. So across the network I would have a different oversight of what the normal operators where I say the SMCs would have. I would be watching all 11 MRCCs as the incidents drop in. Particular distress phase incidents, I wouldn’t necessarily be automatically drawn to them, but I would wait for the SMC to make contact to bring my attention to them. Then we would discuss what their thought process is, what plans they wish to put in place, and then I would offer any guidance should it be needed.
Q. I see. So my understanding then is that you wouldn’t open and proactively review all of the incidents that were put on to the ViSION system; you would wait to be notified?
A. That’s right, yes, because with the amount of incidents that we could be dealing with it was impractical to go into every single one of them to review it. It would be down to the SMC to make contact to draw my attention to that particular incident.
Q. So would that depend then on how busy a shift was if the reason for that was that you had too many incidents to look at? If it was a quieter shift or if there were two Maritime Tactical Commanders on duty, would you then be in a position to review each incidents?
A. Yes. If there was two of us on, that would be the case because we could evenly distribute the workload. Once you are a single Tac Commander looking after the whole of the UK national network, the workload, it did become quite overwhelming.
Q. And was your experience that SMCs, particularly if there were a large number of incidents, would have the time and would proactively contact you about distress incidents, or was it perhaps more often the case that on a busy night they also might not have time to contact you to discuss an incident?
A. So part of the SMC function would be to deliver a brief certainly to their watch team with what their thought process would be and how they would want to execute that mission. And then part of that brief would be to inform the Tactical Commander, such as myself, of that particular incident and to ensure that what plans they have got in the forefront would be the correct plans going forward, and guidance would be given if not.
Q. So was it your experience that even on busy nights the SMCs had sufficient time and did contact you as Maritime Tactical Commander about every incident that was classified as a distress incident?
A. They would contact me by whichever means they could, yes.
Q. For each incident?
A. If they could, yes.
Q. And when you say if they could, that’s really what I am asking about.
A. Yes, well —
Q. In practical terms —
A. So they would also —
Q. — was it your experience that they did have time and they were able to contact you, or was it equally a difficulty for them that there were such a large number of incidents that there was insufficient time for that interaction with you?
A. It would be difficult for them on occasions. Sometimes they would maybe pass that function to another member of the team that may not be as actively involved just to raise my attention to that, that particular incident.
Q. And so was it your experience before this date of 23/24 November, that by one means or another either the SMC or another team member would and did raise your attention to every distress incident log, or were there some which you simply wouldn’t have your attention drawn to during a shift?
A. There would be some that I wouldn’t have my attention drawn to during the shift, but there were others where I would.
Q. And was it your experience that on busier shifts it might be more difficult for the SMC to find the time to contact you about distress incidents and discuss them?
A. Yes.
Q. Did you have any particular approach on busier shifts to ensure that you were interacting with the SMC to make sure that any incidents you needed to advise on you were aware of?
A. If I had the time to do so and if they had the time to speak to me, yes, because I didn’t want to put extra workload on to the SMC whose sole focus would be to prosecute that mission to a successful conclusions.
Q. And you have explained in your statement that there was an increase in small boat incidents prior to November 2021. And is it the case that this had impacted on your ability to review and, in particular, add RAG ratings for all incidents when you were acting as a Maritime Tactical Commander?
A. Yes, that’s correct.
Q. But ideally you would review them and add a RAG rating; you just weren’t always able to?
A. Yes, that’s correct.
Q. And you say in your statement at page 3 and paragraph 11, which we have got on screen in front of us, that you would provide support and guidance if needed by a particular SMC but this was relatively rare?
A. That’s correct, yes.
Q. And in your experience, you say you would always be available to provide support elsewhere in your statement. How would that happen? What sort of incidents would be called upon to assist with?
A. So if there was either a major incident that would have been declared or an incident that needed extra resource, so we would then bring resource to the problem, whether it would be allocating extra staff from another MRCC to remote in by doing zone flexing or any other means that we could do it.
Q. So were you typically contacted not because of the complexity of an incident and a need for advice on steps to take, but because there was a need for additional resource that only you could allocate?
A. No. They would also come to me if they had explored all the avenues, because I would have that helicopter view, so to speak, and I may be thinking of something that they may not have thought of. So they would come to just reaffirm what they have done is correct and had they missed anything, or could I think of anything that could add extra to their thought process.
Q. Aside from the size of the incident and the resource need or the complexity of the incident, was there a particular level of seriousness of an incident where you would expect to be called or notified by an SMC because this was a very serious distress incident, for example?
A. Yes. I would expect to be notified, especially if there was reports of potentially multiple persons in the water, a collision between two vessels, and so on.
Q. So if there was a vessel and it was reported to be taking on water or people had entered the water, you would expect to be notified?
A. Yes.
Q. If I ask you to turn to page 4 of the statement, and we will look at paragraph 13, {INQ01038/4} you describe there the structure of HM Coastguard. And at paragraph 13 you explain there was a minimum requirement of having one Maritime Tactical Commander each watch, although two was better to improve oversight, reduce mental fatigue and ensure rest breaks, but that it was not uncommon just to have one. And you have explained specifically already that one impact was the ability to review incidents and insert RAG entries onto those. Was this a long-term issue that you had experienced, that it wasn’t uncommon just to have one Maritime Tactical Commander, or was that something more recent?
A. That was something more recent, around the time due to Covid isolation and sickness due to Covid. So that did prove — that did sort of pause that difficulty in maintaining the two ideally maritime commanders on watch at any one time.
Q. Were you aware of any steps that were taken in relation to that, that there was an issue that there was often only one Maritime Tactical Commander to try and mitigate that, or try and obtain more cover elsewhere?
A. Not until the day that you would come in to watch. But you — during a day shift you would normally have another commander somewhere in the network to be able to support, but generally at nighttime it would just be the one.
Q. Because of the Covid issues?
A. Yes.
Q. And you explain at paragraph 14 that you would work alongside the Air Tactical Commander who had a similar role to you but in relation to air assets, and that you were located next to each other in the same room in the JRCC. I understand that there may have been a time when Covid required different arrangements, but on 23 and 24 November 2021, were you working directly alongside each other?
A. So we weren’t directly alongside each in terms of sitting desk to desk, but we were in the same operations room within talking distance and where we could go and have that chat if we needed to.
Q. So you could speak face-to-face?
A. Yes.
Q. Would you be able to overhear what the other was saying on the phone? Were you that close to each other?
A. No, we weren’t that close.
Q. And at page 4, paragraph 15, you explain that the rank above you was a strategic commander above whom would be the duty operations director. And the role of the strategic commander who had to be called in in certain situations, such as a major incident or multiple fatalities, or when significant SAR support was requested from another state. Can you confirm how frequently, if at all, you recall contacting the strategic commander before this incident in relation specifically to small boats crossing the Channel?
A. It was very rare.
Q. Had you ever?
A. I think I can probably recall once or twice.
Q. What kind of matters had you reported to them about?
A. I cannot recall, I’m afraid.
Q. Would you ever contact them if there were concerns about staffing levels?
A. Yes.
Q. And would you ever contact them if there were concerns about the availability of a maritime picture for small boats?
A. No, not really, because that would be something that myself and the air commanders we did on this particular night, would try and find a solution to the problem, and then we would try and implement that, that solution.
Q. And you have explained that one of the matters that you would contact the strategic commander about would be a major incident situation. Who would determine whether it was a major incident such that you had to call that commander?
A. So there would be trigger points that we would have to follow, which I can’t recall what these trigger points would be. But once we had met those points we would — I would then make contact with the on-call strategic commander, give them a brief of what the incident was just to make sure that what I believe to be has hit those triggers. They would either agree or disagree and then it would be implemented from there.
Q. Do you recall whether you had ever contacted the strategic commander in relation to a small boats incident that you thought might constitute a major incident?
A. Not that I can recall, no.
Q. At page 5 now of your statement, and paragraph 17, {INQ01038/5} you explain there that as the Maritime Tactical Commander you would have had limited contact with other agencies; you say you would have had none, at subparagraph (b), with police forces, the National Crime Agency or French authorities in respect of migrant crossing?
A. That’s correct.
Q. And you say you would have limited contact with Border Force. Can you explain what contact you would have had, if any, and what that would involve?
A. So the only contact I would have had with Border Force would be if I was on duty and dialling into the Op Deveran migrant reporting days. That would be the only interaction that I would have with Border Force.
Q. And Border Force might provide information in an Op Deveran call. Other than that, were there any channels of communication by which they would provide you with information relevant, for example, to the number of crossings predicted?
A. Not directly to myself, no.
Q. Would you receive that type of information through any other channel from Border Force?
A. Not that I can recall.
Q. And in relation to information sharing within HM Coastguard, I think it’s right to say you would attend red days meetings when you were on shift when they took place?
A. That’s correct.
Q. Could we bring up {INQ000204/1}. This is a record of a red days meeting on 19 November 2021. That’s one we can see that you attended. Your name is on the attendee list?
A. That’s correct.
Q. If we turn to page 2 and paragraph 4, {INQ000204/2} we can see there that there is a section that addresses risks to effective response. And under that, there is a section that starts “maritime assets” and it refers to the: “… RNLI – only concerns – crew fatigue – all lifeboats crewed – no perceived shortfalls …” Then it goes on again to refer to potential crew fatigue. If we turn on to page 3 and perhaps keep the two pages next to each other, 2 and 3, there is a reference there to looking at a potential for plans for duty rosters over the weekend. So that was before this incident. But to your knowledge was this issue of pressure on RNLI assets in particular something that was resolved by 23 and 24 November?
A. I wouldn’t say it was resolved, but there were mitigations being put in place to help alleviate that, because it was recognised that the RNLI crews specifically around the southeast corner were out for long periods. And what we have got to remember is with the RNLI volunteers they have got other day jobs, so they were getting very fatigued.
Q. And you say that there were mitigations that were being put in place. Do you know what those were?
A. I can’t recall what they were, I’m afraid, sorry.
Q. Was it your understanding on 23-24 November that RNLI assets were available to be tasked without restriction, or that there should be a wariness about tasking RNLI assets because of this issue?
A. Not that I can recall, no.
Q. Sorry, which —
A. I can’t.
Q. — that they could be tasked —
A. They would be tasked normally as a reactive search and rescue mission, because that’s what they are there to do. But I don’t recall anything else being put in place for a reactive or proactive surveillance.
Q. And it is right to say some red days meetings would have taken place when you were not on shift or weren’t able to attend. Would you have been made aware of information shared during those meetings?
A. Only if it would affect my period of duty.
Q. And how were you made aware when it might affect your period of duty?
A. That would either be by email, which I wouldn’t pick up until I got back in from my period of duty, or it would be a verbal handover from the offgoing Tactical Commander I would be taking over from.
Q. If we have a look then at {INQ000206/1}, we have there the red days meeting for 22 November 2021 at 4 o’clock. We can see that you weren’t in attendance at that meeting, but obviously others of your colleagues were. If we look at page 3 of this document {INQ000206/3}, there is an entry, it is sort of the second block of text there by the initial “DL” that records: “The boat launches at the weekend were significantly earlier than expected which resulted in rapid launches.” And then beneath that someone else speaks, ST. The last sentence of that section records “activity moved a lot earlier”. And then there is an entry: “Don’t need to adjust the proactive patrol timings at the moment, although the aircrew should be made aware of the possible change to timings.” Was that something that you were made aware of, that information, do you recall?
A. Not that I can recall, I’m afraid.
Q. Do you recall whether Dominic Golden appeared to be aware of this information and whether you discussed it with him, the possibility that launches were happening earlier?
A. I can’t recall that, I’m afraid.
Q. There was also a concern reflected, if we look at the bottom of page 4, {INQ000206/4} moving on to page 5, {INQ000206/5} perhaps bringing them up side by side, that there was a concern about the possibility, the last line on page 4, of earlier activity on Tuesday following what the weekend was like and considering the numbers at Dover on Tuesday. And then on the next page under the initials “PM”, the last line there is: “The amber days are starting to look more red than amber.” Do you recall whether you were made aware of that specific concern or whether you were more generally aware that even an amber day might look more like a red day now?
A. It was just general awareness from being on shift, when we had amber days, they were increasingly getting busier during those periods.
Q. And in terms of other information sources available to you, you had access to the ViSION system?
A. (Nods)
Q. Did you have access to the HM Coastguard small boats tracker?
A. I would, I could get access to it, but I wouldn’t routinely have it up on my screen because then that could draw me into losing oversight of the rest of the national network which was part of my function as well.
Q. Do you recall on 23 and 24 November whether that was something that you would have —
A. I can’t recall, I’m afraid.
Q. — had on the screen? If we could return to the statement, which is {INQ010138/6-7}, we see there that under the subheading “Small boat migrant incidents” at paragraph 26, you explain that the number of small boat incidents grew significantly from around 2020, but particularly in 2021. When do you recall first becoming aware of small boats as an issue that HM Coastguard was responding to at all?
A. I think the early part of when I started down there as what was then a maritime controller back in 2016, there was small number of incidents. But as time went on they progressively got more complex in numbers, so it was from 2016 onwards.
Q. And was the increase particularly in 2020 and 2021 having an impact on your role as network commander or others you managed?
A. Yes.
Q. In what respect?
A. In terms of manpower, in terms of support, in terms of overwhelming not just staff but also the Tactical Commanders that would be on shift, especially if there was one, because your workload would obviously increase. So that would become problematic as well.
Q. Was there also an impact due to the particular complexity of small boat incidents?
A. Yes, because of the nature of them, they are very difficult to identify, very difficult to locate. And sometimes it’s — it was just generally more difficult than a normal SAR response incident where you would get what we call a last known position.
Q. And if we look at your page 7-8, {INQ000206/7-8} just turning to that double-page spread, at paragraph 33, the bottom of page 7, we see there that you describe awareness of calls originating where people might be coached to exaggerate levels of distress, and you identify that that was an issue although you didn’t have firsthand experience of it. What impact, if any, did that have on HM Coastguard, its response and resourcing of incidents?
A. So that would have had an impact in terms of the deployment of assets, because we can only go based on what information we are given and the facts. So that had a massive impact on the deployment of the resources that were available.
Q. Do you mean because you had to respond on the basis that all of the calls were true, that everything was being said was true, and that was using up more resource, or something else? Sorry, I am not sure I understand.
A. Yes, because you would have quite a number of calls coming from maybe one particular boat. It wouldn’t be just one person on that boat ringing, you would have quite a number. And until we could ascertain that they were on the same small boat, we would have to treat each call as a different call. So that would be time-consuming.
Q. I see. Was there also an impact due to the number of incidents, setting aside the number of calls?
A. Yes. From me as a Tac Commander, again, each call that came in from a small boat, certainly if it was in UK waters, would automatically go into the distress phase incident. And that would then have an impact for me in terms of the rest of the network with distress incidents, I wouldn’t be able to locate other distresses across the national network, and in terms of the RAG as we touched on earlier.
Q. And at your paragraph 29 on page 7, you explain that there were issues to do with staffing levels and that HM Coastguard did take steps to assist with this but it was a slow process. If we look at your page 9 at paragraph 37, again, you say in November 2021 you recall concerns about the manning at Dover and insufficiency of qualified staff which was being addressed but not a quick fix. From your perspective had there been any tangible increase in staffing resourcing at Dover in response to this issue by the date of the incident in November?
A. So we had put out across the network for volunteers either to be a remote operator for Dover to give that extra manpower, or later on we did put out expression of interests for people if they would be happy to go down to Dover for a period of time and to help alleviate that problem while a permanent solution was being sought.
Q. And was it your perception that that had resulted in an improvement in the situation?
A. It was a minor improvement, yes.
Q. And you have explained that the Covid situation impacted on availability of Maritime Tactical Commanders. Was that something that impacted more widely on availability of staff?
A. Yes.
Q. And so at the time of November 2021, was insufficient staff resource from your perception an ongoing issue particularly at Dover?
A. It wasn’t particularly at Dover, it was particularly across the national network.
Q. Impacting Dover and elsewhere?
A. Yes.
Q. Including the JRCC?
A. That’s correct, yes.
Q. And there was a system that I think you touched on there of remote support and zone flexing within the HM Coastguard network, and that included provision of remote support from the JRCC to Dover MRCC. You address that in your statement at page 2, paragraph 8, explaining it was known as zone flexing and that your role was to allocate resources from other MRCCs if needed. How effective was that system in your experience?
A. Very effective. In terms of if there was a complex incident that was going on, we would leave the zone of that incident with the co-ordinating MRCC and the additional zones that they would look after would be flexed out across the national network to allow them to solely concentrate on the mission at hand.
Q. And what did the remote coverage rely on to work effectively?
A. Staff numbers.
Q. And was there any issue in relation to the location of the staff, particularly if you were dividing incidents in the same zone, for example?
A. So we would try not to divide the incidents in the same zone, but we would certainly look at what we could do to assist in helping the staff prosecute those extra incidents.
Q. And if we could bring up {INQ000411/1}, you will see this was an email, the second email down, sent on November 19 by Helen McCaffery, deputy chief coastguard, and it put in place network changes to provide network support, in particular the MRCC Dover retaining responsibility for small boats and SAR activity in zone 14 with the JRCC providing support if requested, but with other aspects moved to different zones — rather the zones were moved to different MRCCs. Were you aware of this temporary operating instruction —
A. Yes, I was.
Q. Had you been on shift since this had been in place before 23/24 November?
A. No, because I think that was implemented on night of the 19th from the 19:00 shift where I would be coming on to days — it was either at the end of my shift or the beginning of my round, but I was aware of it and that was something I factored in when I was doing my network briefs to the national network.
Q. So was this the first time you dealt with this new system?
A. Yes.
Q. If we turn back to your statement and page 7, paragraph 30, {INQ000138/7} you explain there that there was a new role of Small Boats Tactical Commander which had been created and they would come on shift when migrant activity was forecast to be at its highest. In your paragraph 31 you say your role stayed the same whether or not they were on duty because your responsibility was oversight of the national network. And at paragraph 32, that if the SBTC wasn’t on duty it would not be your role to assume their function. How, if at all, would the SBTC work with you when he was on duty?
A. So they wouldn’t work directly with me unless they felt that they needed additional support for the team at Dover. They would be in the operations room with a team co-ordinating the small boats. So he would be there to give that tactical oversight and advice, guidance, if it was needed.
Q. Would there be any changes to channels of communication between you and Dover if he was on shift?
A. Yes, I wouldn’t have any contact with them.
Q. With Dover at all?
A. No.
Q. So he would take responsibility for monitoring small boat incidents. And would he have any responsibility for resourcing needs in Dover and communicate and update you about that?
A. He would communicate with me if he needed extra resourcing, yes.
Q. Whose responsibility would it be then to make the RAG entries?
A. That would be down to the small boats commander, I believe.
Q. So did you find that when the SBTC was on shift it assisted you in your own role because there was someone else who could take the burden of dealing with the numerous small boat incidents?
A. That would be the case, but I don’t believe that I worked a busy small boat crossing night where there was a Small Boat Tactical Commander on shift.
Q. And in relation to your training for responding to small boat incidents and awareness of them more generally, at page 3 to 4, paragraph 12 of your statement, {INQ000138/3-4} you provide details of your training. And what training you had, it is sort of really I think 3 to 4 if we have them side by side, you say that you would not say you undertook any specific training about SAR in respect to small boat crossings. So is it right to say that you never received, to your recollection, any specific small boat training?
A. That’s correct.
Q. And none, for example, in the autumn of 2021?
A. Not that I can recall, no.
Q. Were you aware of any HM Coastguard policies relating specifically to small boats?
A. Yes, I was aware of the standard operating procedure that was located on OMS, the operation management system.
Q. And did you receive any training on that?
A. Not specifically. Not that I can recall.
Q. How would you have become aware and familiar with that?
A. That would be cascaded through what we call a hot topic, and it would be down to the individual then to read that document to make sure that they are aware of where it was and where to locate it if needed.
Q. If we turn now to {INQ000231/1}, we have there the network management log for 23 November 2021. There is an entry towards the bottom of that page that’s under your name, just after midnight on the 23rd, which shows a network briefing on 22 November given by you and Dom Golden. Does that indicate you were on the night shift of 22nd and 23rd?
A. That’s correct, and 23/24. That was my block of two nights.
Q. I see. Yes, okay. If we look at page 17 of this document, {INQ000231/17} we can see there at an entry under your name at 18:48 towards the top of the page, showing that you were now Tactical Commander. So that’s the start of your shift on the 23rd?
A. That’s correct, yes.
Q. Then there would have been, later on that night, a network briefing at 9 pm?
A. That’s correct.
Q. Prior to that there had been a call between Neal Gibson and Tom Barnett at 19:39 and a call between you and Neal Gibson at 20:31 hours. Do you recall what role Neal Gibson and Tom Barnett had that night?
A. So Neal was the SMC at Dover and Tom Barnett was one of two team leaders, SMCs, at the JRCC.
Q. And if we bring up {INQ010128/1} we have there the transcript of the call between Neal Gibson and Tom Barnett at 19:39. If we turn to the next page of that, {INQ010128/2}, we can see there that there is a call from Tom to Neal. Neal says, the third line down, that he is running around like a headless chicken and there is a question from Tom Barnett about halfway down the page: are we expecting lots this evening? Neal Gibson says: “It’s amber, and who knows? Border Force have stood up all their assets to call us if you need us, rather than we’ll go out and have a look.” He says it is amber and red tomorrow. If we turn to page 3 {INQ010128/3}, there is there an entry from Neal Gibson, the third entry down from the top, that starts: “I’ll be keeping a large ear on channel 16 in the French channels, just to get heads up early, because they’ve not been playing ball.” Then there is a discussion. Tom Barnett: “Are they not letting us know again?” Neal Gibson: “Sometimes they just seem to keep it quiet. Like we’ll not get anything, and then we’ll get a tracker at 3.00 in the morning with 15 incidents,” etc, etc. Then there is reference to this being a grenade bomb, from Tom Barnett. If we go down to the bottom of the page, Neal Gibson says he’s got to do VTS as well and he is probably not going to get any breaks tonight. Then if we turn to page 4, {INQ010128/4} two-thirds of the way down we can also see an entry from Neal Gibson: “– it means taking us in a oner. Well, I might just have to miss my break.” Take down that document and put up {INQ010129/1}. This is a transcript of your call with Neal Gibson at 20:31 hours, and if we could put the next two pages up side by side that’s the complete call. So it is a much briefer call between the two of you. Neal Gibson says, the large paragraph down on the first page: “… I just thought I’d touch based because this may be the last time we speak tonight before I get overrun.” He says he has spoken to Tom and they have got a bit of a plan pending workload, and he then asks you whether George has been tasked to come in. That’s the Small Boats Tactical Commander, isn’t it?
A. That’s correct, yes.
Q. You say “no idea”, and he then refers to the situation on the first amber night and red night tomorrow. Then you say given him a ring just to see, see what the plan is. Neal Gibson, towards the bottom of the page, says he was in today but he didn’t mention anything. He wondered whether anything had been mentioned at a strategic level over his head. You say give him a ring, and then that’s pretty much the end of that call. Did this call — if we take down that document — put you on notice that Neal Gibson had particular concerns about that night and the capabilities at Dover?
A. Yes, because prior to the network brief at 21:00 we had had a discussion around what support we would put in place in terms of SMC support when Neal was covering VTM breaks, or VTS breaks, and likewise for his staff to have breaks. Where they alluded to that we would take them in a oner, that would allude to us taking Dover in its entirety into the JRCC until such time they had completed their meal breaks.
Q. So you say you had had a discussion before the network briefing. Who had you had that discussion with? With Neal or with —
A. I think it might have been with Tom. That may have just been a face-to-face just to say this is what I’m going to propose in the network management call, would there be something that we could facilitate.
Q. And did Tom speak to you about what had been discussed with Neal Gibson in the call we have looked at already that came slightly before yours?
A. No.
Q. So were you aware specifically of Neal’s concern expressed to Tom Barnett that they might receive information from France late and that there might be effectively a grenade that hit them?
A. Not that I can recall, no.
Q. Were you aware of Neal Gibson saying he might not get a break?
A. No, I wasn’t.
Q. And from your own conversation with Neal Gibson and awareness of his concern, did you think you needed to monitor Dover more closely, because he obviously was asking for support either from the Small Boat Tactical Commander or elsewhere?
A. No, because it would have been impractical for me to just solely focus then on Dover, because I would have lost oversight of the national network if anything had happened elsewhere, whether it be technical infrastructure, manning due to short-term sickness or late sicknesses. So no, it wouldn’t have been practical for me to have that oversight.
Q. So you were aware that there was a concern from Dover, but effectively because you were the only Maritime Tactical Commander on shift you didn’t feel you could offer any more support than the standard?
A. Not — other than the support that the JRCC was going to give, and Tom and Neal were going to sort what best support they could give amongst them, because I’ve empowered them to do that in terms of that mutual support.
Q. And if we turn now to {INQ008822/1}, we have there, you will see, the transcript of the network management call at 21:00 hours that you have referred to that was led by you and Dominic Golden, who was the Aviation Tactical Commander. If we turn to page 4 {INQ008822/4}, we see there an entry, the third down from you, where you provide an introduction and you confirm that it is 23 November at 21:00, and then you talk about zone allocation towards the bottom of the page. If we bring up the next page as well, {INQ008822/5}, you have explained that you were aware of the TOI that took some zones away from Dover, but you say at sort of the fourth line down from the top here: “If the workload is excessive, then zones 11 and 13, which are Dover zones, I would like them to fall back into Dover for that period of transition if the workload is excessive across the network.” So is it right that you foresaw that although Dover was under pressure, it might be necessary for them to nevertheless re —
A. No, what I was referring to there was my business continuity plan. So if the JRCC was to be incapacitated in any way, whether it be through a technical issue, a fire alarm or evacuation, then the JRCC zones would have to be distributed across the national network to maintain business. So for that short period, whether it would be 30 minutes or 40 minutes while we get across to either the business continuity suite or we are allowed back into the control room at the JRCC, I would have to put zones across to the other stations. And to ease that workload at the time, obviously if it had been during the smaller hours that would have been dynamically risk assessed again, but certainly during the routine periods I would have expected 11 and 13 for a small portion of time to fall back to Dover while the JRCC staff either relocated or were allowed back into the control room.
Q. So you said that would be the case if the JRCC was incapacitated. But looking at what you said during the call, it was if the workload is excessive — you would like them to fall back into Dover if the workload is excessive across the network?
A. So I think, from what I am getting at there is that that would rely on my business continuity plan. Because if you look at the top, it’s got zones 15, 13 to 18, and the 999s go to Holyhead. 19 to 21 would go to Stornoway. So what I was doing was trying to equally portion the JRCCs zones across the network to allow business to function while we either relocate or get clearance to come back in.
Q. I see. If we turn to page 7 {INQ008822/7}, we can see there an entry from Dominic Golden. In brief, he explains a concern about the weather, that there was freezing, level coming down, any precipitation which was likely to fall was going to come down as snow. He says that’s an issue, and then he also describes looking at sort of quite thick fog and mist, certainly by the early hours of the morning, both on the French side of the Channel and the English side. Towards the bottom of the page he refers to the fixed assets, and then if we turn to page 8 {INQ008822/8}, we can see the bottom of his entry on that page three lines up from the bottom saying that is all weather dependent because if the weather goes out of limits, that is going to happen. Presumably that should be “that isn’t going to happen”?
A. (Nods)
Q. Yes. And then we see at page 8 your entry which follows that, which refers to the fact that it’s an amber night. So there is potential for migrant activity which is quite high. Then if we turn to page 9, {INQ008822/9} the third paragraph of your entry there. “Moving on to AOB.” It seems that you are suggesting people should take their breaks as early as they can because it’s likely there will be more support needed later for migrant activity?
A. That’s correct, yes.
Q. Then if we turn back to {INQ010138/8}, you explain at page 8, paragraph 36 of your statement, the set-up on the night. That is that there were five personnel at Dover: an SMC team leader and a MOO assigned to SAR assisted by a trainee, with two MOOs assigned to VTS. And that at about 5, a second SMC was due to join the watch who had been loaned to provide watch continuity and support. Is that right?
A. That’s correct, yes.
Q. If we look at page 10 {INQ010138/10} and paragraph 40(c) of your statement, so turning on to the next page, you explain that you had allocated the JRCC to provide support to Dover MRCC when they were on breaks. And then at 40(d), that the JRCC would also give support throughout the night to Dover MRCC with two staff members provided for dynamic assistance, one for VHF channel 16, the other to assist with SAR. What did you mean by dynamic assistance in this context?
A. So they would remotely log into the Dover zones and be a virtual Dover operator for the period that they would have been allocated by their team leader. I would have leave that to the team leader to identify which staff, two members, he would give to Dover and they would then become Dover operators for that period of time.
Q. From your experience was that remote assistance equivalent to having two more staff members present in Dover, or would there have been advantages to them all being colocated?
A. There would have been advantages to them being colocated, because you don’t get a feel for the workload in the room and you don’t get the full big picture or situational awareness of what the workload is like from a remote perspective.
Q. And then if we turn back to page 4 and paragraph 13, {INQ010138/4} we have touched on this already, that it was a minimum requirement to have one Maritime Tactical Commander, but better to have two. And that if we look at page 8, paragraph 35 again, of your statement, {INQ010138/8} you explain that there were supposed to be two, but due to illness one was not available?
A. That’s correct, yes.
Q. You have already explained how it would be helpful to have another. If we look at page 7 and paragraph 32, {INQ010138/7} you had been called, we have seen, by Neal Gibson to ask about the Small Boats Tactical Commander, but you confirm at paragraph 32, as you have said, it was not your role to assume the functions of the SBTC and you have said I think that you weren’t able to provide additional support to Dover because of your position being the only Maritime Tactical Commander?
A. That’s correct, yes.
Q. Did you consider that you were able to be on top of small boats activity that night?
A. Yes, I believe that the team at Dover with the support that was put in place, that they were managing the workload. I didn’t have a full picture of what the workload was like within the control or the operations room, because obviously I wasn’t there, I was at the JRCC. But I felt with what mitigations we put in place that they would have been able to fulfil that.
Q. And were you able to follow any or all of the small boats on ViSION proactively, remotely, or only if you were called upon specifically?
A. Only if I was called upon, because of the rest of the network I had to keep oversight of as well.
Q. Do you recall looking at any small boats incidents logs that night?
A. Not the specific ones, other than the administrative log to start with. And then I would look periodically. If there was anything that raised any sort of questions or any eyebrows then I would look into them, but I felt that everything was being dealt with as they should be.
Q. And how would you know there was anything that raised questions or eyebrows until you were already in the logs? Were you reliant on others to tell you you ought to be looking at them?
A. That’s correct, yes.
Q. Do you recall whether you were asked to look at any logs that night?
A. Not that I can recall, no.
Q. And you were aware, I think, from your statement that you were informed — if we look at paragraph 43, page 11 of your statement, {INQ010138/11} — around 00:30 that the planned Excel fixed-wing aircrafts were postponed, and you say that was something that was of real concern to yourself and the Air Tactical Commander. So it is then, you explain at paragraph 44(a), that you asked for the migrant administration incident log to be created so that you could add contents around that. If we bring that up, it is {INQ000235/1}. That is the log that you have requested to have created, and if we turn to page the bottom of page 2 and the start of page 3, if we have them side by side, we can see an entry from you right at the bottom of page 2, {INQ000235/2} 00:41 hours, D Jones, and you explain there an action plan. It starts really at page 3 {INQ000235/3}. You were aware of 2Excel postponing their sortie and your entry there on the right-hand side records that we are effectively blind and the night had the potential to be very dangerous. In your statement at paragraph 43, you say that was something of real concern because migrant activity was likely and there was no situational awareness. Was this an unusual situation for you to find yourself in as a Maritime Tactical Commander?
A. Yes, because we were — more often or not we would get an aircraft to do some sort of surveillance for us, which would be preplanned with 2Excel. But on this particular night in question, due to the weather and other limitations which I wouldn’t be privy to because that would be down to the air commander to deal with from that perspective, that did prove a problem.
Q. Had you been on shift previously on an occasion where there wasn’t something to provide a maritime picture?
A. Not that I can recall, no.
Q. Had you considered or had any training or guidance on contingency plans if you were put in that situation in relation to small boat crossings?
A. Not that I can remember, no.
Q. Did you give consideration at that stage to contingency plans?
A. Yes. Where myself and the air commander had the discussion around the potential of the use of the helicopter to give us that maritime picture. So we had that situational awareness of the maritime domain and what we could expect.
Q. Just before we move on to that, in relation to the entry being put into the migrant log, did you consider also putting that into the network management log to ensure that it was picked up by everyone who needed to see it?
A. No, because everybody that would be involved in small boat activity would only be looking at the administrative log for migrant activity, not the national network.
Q. So your expectation would be anyone involved in that would be checking this log?
A. That’s correct, yes.
Q. So you have described the fact that you and Dom Golden were aware of the fact that there was a difficulty with the fixed-wing aviation, and you say this message was warning MRCC Dover to stay alert. What did you mean by staying alert and did you follow up with Neal Gibson to ensure he was aware and taking any appropriate steps?
A. No, I didn’t follow up with the SMC at Dover because I would have expected them to have seen the incident log, and I can’t recall if I did follow anything up with him.
Q. I see. If we go back to your statement {INQ010138/13}, paragraph 45, this is where you explain what you have started to say, which is that you began planning with Dominic Golden. First, was there any discussion during your planning of the fact that RVL were tasked to fly that night? Was that something you were aware of?
A. No, I wasn’t.
Q. Did you understand at the time that RVL could be retasked, if they were flying on behalf of anyone else, to provide a maritime picture?
A. No, I wasn’t.
Q. Was there any discussion of requesting Tekever to move their planned tasking earlier in the night?
A. Not that I can recall.
Q. Is that something that you understood could be done?
A. Yes, because I think that it could have been put through to the pilots for Tekever. But, again, it’s something that I can’t recall did happen or would have happened.
Q. And you explain at your paragraph 46 that you couldn’t send surface vessels out on surveillance missions. You give various reasons. Those include saying at (a) you didn’t have vessels available to undertake surveillance missions. Then if we turn on to page 14, in{INQ000138/14} at paragraph (g) you also describe effectively that tasking them in that way might result in them being unavailable to respond elsewhere, and that there were limited assets. So if you had had unlimited assets with no restriction on deploying them, would you have considered at this stage deploying a maritime asset either for the maritime picture or so that they were closer to the relevant location in order to respond more quickly at the median line when boats crossed it?
A. No, no, I wouldn’t have, because you don’t know where within that median line they are going to cross. The zone 14, which is the zone that particularly has the small boats in, is quite a vast area and you run the risk of what we call an escaping target. So you could have your surface vessel at one end the zone and a small boat coming through at the opposite end, and therefore it would be missed. So it wouldn’t be practical at all to put a surface vessel out there.
Q. Were you aware there might be a delay in deploying a surface vessel when you had a specific location to deploy them to?
A. No, I wasn’t.
Q. How quickly did you think that they would be able to reach a point on the median line if tasked to it?
A. It would depend on various factors: the speed of the asset, the sea conditions and how long it would take for the crew to actually get that vessel started and ready to go.
Q. And you have said that the reason you wouldn’t deploy even if you had more assets was that if you had a surface vessel at one end of the zone you might have an escaping target. If you had unlimited vessels and you could put them in various areas of the zone, would you then have deployed them?
A. Yes, that would be the ideal situation.
Q. We are aware that Dominic Golden had various calls with the captain of R 163, the SAR-H, which resulted in them agreeing to deploy. And he has confirmed that when the entry was made about postponing the sortie, he was concerned about a lack of a maritime picture creating risk. In his oral evidence he said he had a discussion with you about that because he wanted to ensure you were aware that what he described as the normal queue of information that he was expecting was now suddenly going to become disrupted. And he said that he did not think he had a plan B., effectively, if 2Excel couldn’t fly in terms of tasking other fixed-wing assets because he didn’t believe he could retask any of them, RVL or Tekever, to undertake a similar tasking. He said he didn’t expressly inform you of that, but was that your understanding that he didn’t have a fixed-wing alternative?
A. That’s correct, yes. That would be my understanding.
Q. And he said he was trying to nudge the maritime commander, that’s you, possibly into thinking is there something he can provide with his assets he’s got available that he might be able to start going, albeit, he says, with the benefit of hindsight there was nothing that you could have done either. Did you get the impression from him that he was trying to nudge you to consider what you had available?
A. No, it was a discussion. I was fully aware of the limitations that we had in terms of surface vessels, so that was more of a discussion rather than I think the air commander’s choice of words; a “nudge” was a little bit tongue-in-cheek. It was more of a discussion.
Q. And as regards the use of the SAR-H, which was later deployed, he said in oral evidence that he wasn’t expecting small boats to cross the median line until 3 am, so he thought it was sensible to preserve the use of that helicopter so it wouldn’t be deployed until later because of limited flying hours. Were you aware that that was a consideration of his?
A. Yes.
Q. And were you aware, at any stage, that there had been concerns about small boats crossings coming earlier so that 3 o’clock was no longer the relevant time to consider?
A. No, I wasn’t.
Q. Did you —
SIR ROSS CRANSTON: Ms Meredith, I am just wondering —
MS MEREDITH: Yes, perhaps a small break.
SIR ROSS CRANSTON: Do you need a break?
MS MEREDITH: No. I mean if you would like one.
SIR ROSS CRANSTON: Well, I am just wondering how much longer do you think you have got?
MS MEREDITH: I think there 15 minutes longer so it might be that it’s sensible for us to have a break at this point.
SIR ROSS CRANSTON: Well, I think if it’s only 15 minutes, I am not going to hold you to it, but —
MS MEREDITH: Yes, I think I will try and keep it to 15 minutes.
SIR ROSS CRANSTON: Yes. Let’s continue then.
MS MEREDITH: If you are happy to continue.
A. Yes, yes, that’s fine.
Q. So in relation to the SAR-H, you say you didn’t have information that boats might cross earlier but, did you think it might be helpful to check specifically with Neal Gibson or others when small boats were thought likely to cross the median line and then update Dominic Golden with that information?
A. Yes because in hindsight that would — that probably would have been something that I could have done. But I think the other factor that we looked in with the SAR-H helicopter Rescue 163 was there was an identification within the weather window between 03:30 and 05:00 where there would be a chance that we could get them up to do that surveillance patrol for us, which is out of the norm for a search and rescue helicopter because they are reactive SAR rather than proactive.
Q. And on that note, in relation to reactive rather than proactive, Dominic Golden’s evidence was that he did not consider that he was able to task the SAR-H in those weather conditions simply to reports of small boats being in distress even though HM Coastguard categorised them as being distressed. He believed that he required confirmation that there had been a 999 call before he could task the SAR-H to fly. Was that your understanding as well?
A. Yes, because normally when they are in French waters we may have an awareness from the French that we have got vessels coming across and they may not be deemed to be in distress at that particular time. If they were then the French authorities would deal with it. So therefore the aircraft would be preserved for the reactive SAR rather than going up to identify that maybe something is not within the UK waters.
Q. So if there were boats in the UK waters categorised in distress, did you think the SAR-H could then be deployed —
A. Yes.
Q. — or did it have to await a 999 call?
A. No. If we deemed that they were in distress then we, we could request the deployment. However, that would be down to the captain whether he would accept or not.
Q. So you weren’t aware that Dominic Golden believed that he needed a 999 call before they could be deployed?
A. No.
Q. And Dominic Golden’s evidence was that when he first started at the ARCC, he had the same ViSION system so that he could and did check ViSION logs for particular incidents from the maritime side relating to incidents when he needed to obtain additional information but of course he couldn’t do that by November 2021 and he relied solely on information conveyed by the maritime team. Did you appreciate that it was crucial to ensure that relevant information about the small boats reached Dominic Golden and the ARCC team because they didn’t have access to those logs?
A. If it involved a fixed-wing or a SAR-H asset then yes.
Q. So how did you monitor or ensure that particularly in relation to small boats the relevant information about those was being passed to Dominic Golden, the Air Tactical Commander?
A. So that would be done verbally either by myself or by another member of the SMC’s team at Dover or at the JRCC.
Q. So did you take any steps to check logs specifically to ensure that any relevant information was passed or task anyone to do that?
A. Not that I can remember.
Q. If we turn now to can {INQ000235/4-5}, we can see there an entry at 02:31 from you on 24 November 2021 and it summarises a discussion you had with Dominic Golden about air taskings. You set out the difficulties with the 2Excel fixed-wing capabilities and the plan for Dominic Golden to speak to the duty captain of R 163, with them looking to be airborne between 03:00 and 05:30. You then list on the next page numbered points, potential issues that we can see at the moment. Those include 2Excel not launching, the drone due to launch at 05:30, but highly likely it will not be able to. R 163 giving a sweep and that’s what you do have in place and then UK Border Force having vessels on standby with Valiant now deploying to intercept vessels which were deemed in the UK SAR. So you knew at that point that Valiant was being deployed?
A. Yes.
Q. And how did you know about that?
A. That was by reading through the documentation and — So on the night in question, sorry, I wasn’t fully aware of it, but I have now become aware reading through the documents that’s been provided.
Q. Albeit we know from the fact that you made an entry referring to the fact that Valiant was deploying that you must have been aware of that at that time, do you recall how you knew that?
A. No, I can’t, I’m afraid.
Q. And at this stage, did you consider requesting that more SAR-H be deployed from elsewhere?
A. No, I didn’t.
Q. Did you consider requesting more UK Border Force vessels be deployed?
A. No, I didn’t because we were told at the start that they had one vessel ready for deployment which was Valiant.
Q. And did you consider requesting that the RNLI also be tasked?
A. No, I didn’t.
Q. Was there a reason you didn’t consider tasking the RNLI?
A. Not that I can recall, no.
Q. And given the particularly high potential danger that had been identified about the 2Excel flight not going up, was there any reason why the R 163 couldn’t have been put up and tasked at an earlier time?
A. I can’t recall, but I would imagine it would be down to the weather as well that was affecting that particular quadrant of the UK and that’s when we identified from 03:00 through to 05:30 there was a potential weather window where that aircraft could get up and back safely to the home base.
Q. If we bring up your statement again which is at {INQ010138/17}. At paragraph 52 you say you don’t have any particular memory about a Mayday Relay which was broadcast on 24 November and at paragraph 53 you say you have been shown the incident log for Charlie and you understand there was a Mayday Relay. You say you don’t recall reading that entry and you don’t recall also being — at the end of that paragraph — alerted to a phone call in which it was reported that Charlie was sinking. The Inquiry has heard differing evidence about the requirement for and the frequency of Mayday Relays for small boats incidents. Do you recollect whether or not there was a specific policy or guidance in relation to the use of Mayday Relays for small boats?
A. Not in particular for small boats. But there is policy and guidance in terms of — which is international for Mayday Relays where there is a vessel and/or persons that are in grave and imminent danger at sea and a Mayday Relay would be broadcast to try and get other vessels in the close vicinity to respond and assist if they are able to.
Q. So your recollection is no specific small boat guidance, but the standard guidance would apply in the usual way to small boat incidents?
A. That’s correct, yes.
Q. In your experience, how often at around this time, in November 2021, were Mayday Relays made for small boats in practice? Did they occur at all?
A. I honestly can’t remember.
Q. Had you ever been aware of one? Do you recollect there being one —
A. Not that I can recall, no.
Q. — before this? Would you have expected to have been made aware if a Mayday Relay was being made for a boat?
A. If it was to do with a small boat that particular night then, yes, I would have expected to have been verbally told or as, in this case, a flash message was put out but I didn’t see it because of other flash messages on my screen, because I would get them from the whole of the network, so I might have missed it. But I would have expected to have been told verbally one would have been broadcast.
Q. As well as the flash message, would you expect someone to confirm you had seen it to follow up with you?
A. Yes.
Q. And would you also expect to be informed of a report of a boat sinking?
A. Yes.
Q. In the same way, either flash message or contacted or both?
A. Yes, that’s correct.
Q. And if you had been made aware, would you then have made the aviation Tactical Commander aware of either/or both of those facts; that there was a Mayday Relay or a report of a boat sinking?
A. Yes, I would have.
Q. Would you have taken any different action on that evening if you had been made aware of a Mayday Relay or a report of a boat sinking?
A. I would probably have then looked a little bit more into the incident to see what the mission plan was and what was going to be done to prosecute that mission, and what was the actual — because again the broadcast was created from what I am thinking was a call from that vessel or a vessel. But again what the contents of the call would be, I wouldn’t know because I don’t listen into those particular calls but there would be a valid reason why they would have put out a Mayday Relay.
Q. We understand from Neal Gibson that part of the reason why a Mayday Relay was made was that the boat Flamant, the French boat, was thought to be close to Incident Charlie. If you had been aware of that, that that was part of his rationale, is there any advice that you would have given to Neal Gibson about how to address that situation and a desire to have assistance from the Flamant?
A. No, because under international maritime law if a Mayday Relay has been broadcast, the vessels close by have a legal obligation to either respond to say that they can or cannot assist.
Q. And if you were aware that the Flamant had not responded, what would you have advised Neal Gibson to do?
A. To maybe make contact with the French to see why the Flamant hadn’t responded had he not picked up the Mayday because he was not listening on VHF channel 16, was he engaged in something different or did he just not respond to that call for help.
Q. And was it your understanding that Neal Gibson could have requested the French coastguard to deploy Flamant to the incident?
A. No.
Q. That he couldn’t request it —
A. No, sorry, I wasn’t aware that we were able to do that.
Q. But you would have expected it to respond to a Mayday?
A. That is correct, yes.
Q. If we turn to page 19 in your paragraph 58, {INQ010138/19} you explain that you took a meal break for around 90 minutes from around 4 am and you explain that at that point resources had been tasked, the SAR response was being managed between MRCC Dover, the Valiant and R 163 providing air support. And then at your paragraph 64, so I think moving on to the next page, {INQ010138/20}, you say that you have since been shown the incident log for Charlie and it recorded Valiant was on scene by 03:50 and by 04:46 there was an entry that all migrants had been disembarked. Do you recall whether at the time you took your break at around 4 am you were specifically aware of what was happening with Incident Charlie?
A. I can’t recall that I was specifically aware of it. Having now read the documents, that would have been the case, that it would have been close to being resolved before I took my meal break at 04:04.
Q. At page 20, you describe the fact that you looked at the log afterwards and you saw from that that Valiant had been successful at rescuing those on board. Am I right in understanding you are not sure you would have known that at the time?
A. That’s correct.
Q. You had suggested in the network management meeting at 9 o’clock that it would be beneficial for people to get their breaks early to give maximum support later if it was needed for migrant activity since demand was likely to be higher later but you took your break at 4 am. Was there a particular reason for that?
A. So the reason I took my break at the time I did was because I was engaged in the planning with the Air Tactical Commander in terms of getting an air asset up for the maritime picture. And at the time that I took my break I was under the belief that everything was in hand and it was in the process of being resolved.
Q. And did you monitor whether others in particular at Dover had been able to take breaks?
A. No, because I would not dictate to them when they took their breaks, that would be down to them and the assigned MRCC that was giving that mutual support to sort out the timings for their own breaks and I wasn’t aware that Neal hadn’t taken one.
Q. Would that have been a matter of concern for you?
A. It would have been if I had been aware of it, yes.
Q. Then if we turn back to page 21, sorry, turn on to page 21 and 22 of paragraph 67 again back to RAG. {INQ010138/21-22}. You have explained that you were aware of the process for inserting RAGs, that there were some difficulties when you had fewer and you address the process in more detail here; that within 30 minutes the Tactical Commander, at paragraph 69, was supposed to review information, that you endeavoured to make those entries where possible but that you couldn’t always with small boats. Am I right in understanding it was your regular experience before 23 and 24 November that you didn’t have time to do that?
A. That I didn’t have time?
Q. Yes, on small boats.
A. On small boat ones, yes.
Q. And was that something that, to your knowledge, was common knowledge within HM Coastguard, that people knew that maritime Tactical Commanders just couldn’t cope with the volume?
A. Yes, that’s correct.
Q. Was there any action that you were aware of that was being taken to address that?
A. Not that I am aware of, no.
Q. Can you tell me about the arrangements for the handover to the day watch after you left your shift on 24 November in the morning?
A. So we — as Tactical Commanders we had a PowerPoint presentation that we would use as well as a spreadsheet, which would have the national network staffing levels on what the staff level would be like across the national network for that coming shift for that commander. That would be used for me to hand over to them any shortfalls, any SMC gaps. Then any technical issues that we have either experienced through the night or that they are likely to expect during the daytime, and just general incidents that have been going on across the network through my period of shift and if any needed to be either followed up or revisited, or an oversight needed to be an awareness of them, that’s how we would do our handover.
Q. Do you recall on that occasion whether there was anything in particular in relation to small boats or Incident Charlie that you highlighted?
A. No, because as far as I was aware that incident had been concluded as per the entry —
Q. And you left —
A. — that we saw.
Q. Sorry. You left HM Coastguard in 2022. Can you give a more specific date? Don’t worry if you can’t.
A. I can’t, I’m afraid. I just know it was, it was —
Q. At some point?
A. 2022.
Q. And before you left, had there been any improvements to the resources or staffing levels within your part of HM Coastguard or changes to systems for supporting staff in relation to small boat incidents?
A. There was stuff that was being prepared to be implemented and it was the small, easy fixes that were being done while I was there. But what’s — what’s happened afterwards, I can’t comment.
MS MEREDITH: Thank you. Sir, I don’t have any further questions for this witness.
SIR ROSS CRANSTON: No. Well, thank you very much. I know it’s been a long day for you and your wife, Mr Jones, but we appreciate it. Thanks for your statement and also the evidence.
A. Thank you.
SIR ROSS CRANSTON: 10 o’clock tomorrow. Right, thanks very much. (4.05 pm) (The Inquiry adjourned until 10 o’clock, on Thursday, 13 March 2025)
I N D E X
MR MICHAEL BILL (affirmed) ………………………1
Questions by MS MOFFATT …………………..1
Questions by THE INQUIRY …………………47
MR CHRISTOPHER THOMAS BARNETT (affirmed) …………48
Questions by MS MOFFATT ………………….48
MR JAMES CRANE (affirmed) ……………………..121
Questions by MS HOLLOS ………………….121
Questions by SIR ROSS CRANSTON …………..162
MR DAVID JONES (affirmed) ……………………..163
Questions by MS MEREDITH ………………..163