Dear Mr Smith Noatr GTAFFORDSHIRE Re: Michael HOLGATE (deceased) Date of Birth: 03/06/1955 Date of Death: 20/05/2014 Thank You for your letter of the 4th August 2014 regarding the inquest into the death of Mr Michael Holgate. On behalf of the Canal & River Trust would like to repeat our sincere condolences to the family of Mr Holgate: understand that in the report under paragraph 7 , schedule 5 of the Coroners & Justice Act 2009 and Regulations 28 & 29 of the Coroners (Investigations) Regulations 2103, addressed to Safety Advisor at Canal & River Trust (CRT), you specifically asked for a review of four aspects of the tunnel operation, namely: Communication within the tunnel, 2 Wearing of lifejackets or buoyancy aids_ 3 Wearing of safety helmets
4. Review of safety information given out. On the 26th of August the Canal and River Trust conducted a review of tunnel safety and operational procedures relevant to the incident which led to Mr Holgate's death. In addition we considered what changes should be made, not only at Harecastle, but at all our 45 canal tunnels. The review concluded as follows: Communication within the tunnel It is clear from the evidence heard at the inquest that in some sections of the tunnel the use of sound signals can be ineffective as a mean of communication to persons at the entrances to the tunnel: This is more likely in circumstances where a boat has become separated from the usual convoy arrangement; whereby boats transit the tunnel in groups. Harecastle Tunnel is unique in the regard that it is the only one of the 45 Trust managed canal tunnels which has a mechanically driven ventilation system , with doors which close behind boats when enter the tunnel to facilitate tunnel ventilation. Harecastle Tunnel is one of only 3 tunnels where personnel are present Canal & River Trust First Floor North Station House 500 Elder Gate Milton Keynes MK9 1BB wwW canalrivertrust org uk Patron HRH The Prince of Wales Canal & River Trust charilable company limited by guarantee registered in England and Wales with company number 7807276 and registered charity number 1146792 registered office address First North Stalion House 500 Elder Gale, Millon Keynes MK9 1BB they - Floor

at the tunnel during its operating hours. are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31* March 2015 2 Wearing of lifejackets or buoyancy aids There is no mandatory requirement that lifejackets or buoyancy aids must be worn or carried on inland waterway vessels. The Trust does encourage their use on inland waterways, but the general view of many inland waterway boaters is that lifejackets or buoyancy aids are unnecessary, but this is an attitude that the Trust is trying to change: The Trust will continue to encourage boaters to wear them in the interests of their general safety whilst boating, and we will make particularly reference to safety in tunnels. In direct response to this tragedy we will be encouraging the wearing of lifejackets at Harecastle Tunnel by means of the briefing given to boaters and their crew prior to tunnel As the majority of tunnels are unattended by Trust staff we will modify all existing tunnel portal signs to include a clear recommendation to wear lifejackets. Additionally we will conduct an education campaign using our communication channels with boaters, about benefits of wearing of lifejacketslbuoyancy aids. Although part of a continuous campaign we will complete this initial work by the 319 March 2015 which is the start of the main boating season.
3. Wearing of safety helmets do not believe that issuing safety helmets is an appropriate response to the restricted headroom in tunnels The risks at Harecastle Tunnel are not unique, as in many tunnels if the centre line is not followed when navigating, there is a risk of helmsman or crew members striking their head on the shoulders of the tunnel bore, irrespective of any other restriction in headroom Prior to entering the tunnel the 'gauge board' at Harecastle consists of 3 lightweight chains. We believe these may not be as effective as other alternative measures in making boaters aware of the restrictions inside the tunnel: At other tunnels with similar restrictions on headroom we have physical boards prior to entry. We have concluded that we will replace the chains with a physical board positioned prior to entering the tunnel to put greater emphasis on the restricted headroom: The tunnel portal is a listed building but we plan to complete this work subject to planning consent by 315 March 2015.
4. Review of safety information given out The Harecastle tunnel briefing has been further modified to make clear the importance of wearing lifejackets particularly for the helmsman: Additional information about change of temperature in the tunnel is being included in the briefing as this has been identified as a particular risk of which boaters should be aware These changes have been made_ It is our considered opinion that once the actions outlined above have been completed, the Trust will have done all that is reasonably practicable to reduce the risk to persons navigating boats through Harecastle and other canal tunnels: If you require any further information please contact me_