Review of MAIB report on Milligan family propeller accident in UK
United Kingdom (UK) Marine Accident Investigation Branch (MAIB) released their report on the Milligan accident on 30 January 2014. Nicholas Milligan’s family’s May 5, 2013 accident captivated the UK. An affluent family out for a day on the Camel Estuary at Padstow Harbor in their RIB ended in tragedy with the death of the father and a daughter, the mother lost part of her leg, a son was severely injured, and two daughters received minor injuries.
This post reviews MAIBS’s findings and offers some comments.The report opens with MAIB’s normal boiler plate text about the objective of the investigation is the prevention of future accidents, not to determine liability, and notes the report is inadmissible in any judicial proceeding whose purpose is to attribute or apportion liability or blame.
MAIB historically does a very nice, thorough job of investigating accidents, we just get a little impatient waiting for their reports. This one was published almost 9 months after the accident.
As with their other reports, names of individuals involved are left out. The report is titled, Milly, the name of the RIB.
We covered the Milligan accident at, Nicholas Milligan Boat Propeller Accident at Padstow.
In our view, the important takeaways from the response are:
- How blessed they were to have multiple professionals on the scene at the time of the accident (surf life saving instructor, paramedic, doctor, and a quickly responding ski instructor Charlie Toogood).
- The chaos often results in some misdirection of resources. They key is to anticipate that and respond to correct the situation immediately when it is discovered.
- Just like in the U.S., all the agencies and groups usually work pretty well together, but someone needs to make sure everybody is in the loop. This time Padstow Harbor’s own team was left out a while.
MAIB’s report brings many details to the discussion. This paragraph from MAIB’s synopsis of the accidents pulls much of their findings together:
“On the day of the accident Milly’s owner, his wife and their four children were using the boat for the first time in 2013. During the afternoon, just prior to returning to the mooring, the adults changed over at the helm but the kill cord was not attached to the new driver. A short time later, the adult who was no longer controlling the boat reached across in front of the driver and operated the helm and engine controls to execute a tighter, high-powered turn, and the accident followed almost immediately.”
Mr. Milligan had been operating the boat with the kill cord attached as they made several passes of the Camel Estuary, then pulled into Padstow Harbor for a take away lunch (takeout). Mr. Milligan stayed with the boat and drank some wine while the rest of the family went to fetch lunch. (he stayed with the boat). His family returned and they went out for more boating. Mr. Milligan was still operating the boat with the kill cord attached. After a while they decided to stop for the day. He swapped out with his wife who then took over the boat. She did not attach the kill cord, likely because she anticipated slowly motoring over to where the boat was moored a few hundred yards away. But Mr. Milligan and the kids clamored to go around the Estuary one more time. She started a gradual turn to starboard but was concerned they would not finish the turn before hitting the shore. Mr. Milligan reached across his wife, increased the throttle to full RPM and turned the wheel much more sharply. The report states:
“The boat immediately accelerated and heeled into the turn and then suddenly, and violently, rolled back to port and ejected all its occupants out over the port side and into the water. The boat then continued to circle under full power.
The family were on the surface of the water, supported by their lifejackets and buoyancy aids, and the boat circled back towards them, striking several of them. Mr Milligan and Emily, who was 8 years old, were fatally injured; Mrs Milligan and their 4 year old son suffered serious injuries, and one of the other children was also injured.”
Milly was an 8 meter RIB powered by a 300 horsepower Yamaha outboard with a stainless steel propeller. She was built by APV Marine Limited, known as Cobra RIBs. The boat was delivered to the Milligans’s in April 2012.
Mr. and Mrs. Milligan had both received Royal Yachting Association (RYA) Level 2 powerboat handling training course and both were the only person in their classes. Those courses are typically conducted with outboard boats of 20 to 40 horsepower. The Milligan’s also both received a familiarization trip when he purchased the boat. The family used Milly on about 20 occasions in the summer of 2012 in and around the Camel Estuary.
Milly was serviced, winterized, and placed in storage in September 2012. Rock Marine Services pulled Milly out of storage and placed her on a mooring at Rock on May 3rd at the request of Mr. Milligan.
Interestingly, due to tidal issues, the boat could only be used 3.5 hours either side of high tide (could be used for a 7 hour block centered on the time of high tide).
Post Accident Response
We found this section very interesting. As we have seen in countless other accidents, often, trained medical personnel are onsite and help safe lives by their presence, plus bystanders jump to the rescue, as others promptly notify authorities.
While much went well, as is also often seen, there was some confusion on exactly where to direct ambulances to, and Padstow Harbor’s own crew (the onsite group with the most local knowledge) was left out of the loop.
Accident Response Timeline
At 15:48 and onwards, emergency services received multiple phone calls of people in the water and an out of control speedboat at Camel Estuary.
15:49 a major emergency response began including police, ambulance, and and Coast Guard assets, plus two search and rescue helicopters were mobilized.
15:50 Three canoeist that witnessed the accident (two in one canoe and one in another canoe) arrived at the site of the accident. One of the two people in the double canoe was female and a trained paramedic. The person in the single canoe was a local surf lifeguard instructor. The female paramedic began to triage people in the water, while her companion tried to attract other boats in the area. They managed to pull two of the children into their canoe while keeping Mrs. Milligan and another child alongside the canoe, and keep them all conscious.
The single canoeist tried to bump the circling boat and intercept it. When he learned it was no longer an immediate threat, he let it continue to circle.
15:52 Thunder, a commercial speedboat carrying a doctor arrived alongside the double canoe. The doctor entered the water to help the survivors.
15:56 Cornwall ambulance center contacted Falmouth Coast Guard requesting a gate be unlocked to allow them access to the fields by St. Saviour’s Point (near the accident) from which they could get to the beach.
15:57 Rock inshore lifeboat launched. They arrived alongside Thunder and the two person canoe at 16:00. The lifeboat crew decided to take the injured to Padstow Harbor vs. straight to shore. Thunder and the lifeboat left with the injured for Padstow Harbor.
16:07 the lifeboat crew told the Coast Guard they would be arriving at Padstow Harbor’s south slip and would need immediate medical assistance.
16:11 two other men (unnamed in the report, but known to include Charlie Toogood) partially slowed the circling boat by throwing a rope in front of the boat and fouling the propeller. Charlie Toogood then leaped from his boat into the still circling boat and gained control.
16:12 The lifeboat crew told Famouth Coast Guard they were now at the south slip in Padstow Harbor. The doctor from the Thunder continued to tend to the casualties.
Falmouth Coast Guard contacted Cornwall ambulance control and told them to direct all ambulances to Padstow Harbor.
16:15 Padstow Coast Guard rescue team told Falmouth Coast Guard they were now headed to South Slip along with the other that had previously been directed to Saviour’s Point.
16:16 the first ambulance arrived at Padstow Harbor.
16:20 the single canoeist telephoned Falmouth Coast Guard to tell them he had recovered a body to the beach north of Rock and requested immediate assistance (the body was later identified as Mr. Milligan).
16:37 the rapid response ambulance that had mistakenly been sent to St. Saviour’s Point, arrived at South Slip. Plus the lifeboat crew had gone back out to aid in the search reported they recovered a body (later identified as Emily).
The day after the accident, authorities tried to retrieve data from Milly’s electronic chart plotter (GPS system) and its Engine Control Module (ECM). The charter plotter data was not able to be retrieved as the system had not yet been setup to store data.
The steering system was inspected and found to be fully operational and all oil levels were normal.
ECM electronic throttle data showed the throttle had been advanced to full throttle just prior to the accident.
We are not going to cover it in depth here, but the vessel was found to bank/roll into a turn at a high angle, and if the speed were high enough, it would jump to an even higher roll angle, then the aft end of the boat would begin to slide initiating a partial spin or hook. Then the propeller would hook up again, and the boat would quickly roll the other direction (almost ejecting the professionals). The results were very violent, even to trained professionals running the tests. The handling problem had previously been identified in a magazine review.
MAIB posted a video of their on water testing as seen below:
MAIB investigated the maximum power rating of the boat. This particular design had been acquired from a previous firm. Its paperwork did not exactly align with current regulations. Even so, it probably still met the requirements for a 300 horsepower outboard, except no manoeuvring test was conducted.
Possible Contributing Factors
Some thought Milly might have grounded (struck bottom) in the estuary. With multiple reports and a closed circuit camera tape of the accident, MAIB was able to closely define the exact location of the accident. The Padstow Harbormaster went out and conducted soundings in the area and found the depth in that area to be in excess of 8 meters at the time of the accident. Thus grounding was ruled out.
Mr. Milligan drank some wine while waiting for his family to fetch lunch at the harbor. A post mortem examination found he did not exceed the legal limit for alcohol on the road at the time of the accident. Road limits and boating limits for alcohol are the same in the U.K.
MAIB said they had identified 21 similar accidents beginning in 2005 in which small high speed craft continued to circle after people had been ejected. Those incidents resulted in 7 fatalities and 12 injuries.
Kill Cord Use
The report is very strong on the use of kill cords to prevent similar accidents including statements like, “The use of a kill cord is fundamental to the safe operation of small planning craft.” While we totally agree with the need to use kill cords, MAIB and RYA tend to send that message and ignore some other approaches, such as the new virtual lanyards.
At least MAIB’s report “sort of” mentions them but immediately follows the mention with the need to focus on use of traditional kill cords:
“While technological advances, such as the use of proximity devices/sensors, may prove an effective device on newer craft, the legacy of traditional manual kill cords fitted to older vessels should be the focus of any safety campaign.
By their statement, MAIB seems unaware some virtual kill cords can be installed on existing legacy boats in just a few minutes.
Where to Put the Kids
Children are safer at the stern where movements are less amplified than in the bow area when traveling and turning at high speeds. MAIB says if the Milligans had been taught that, they would have likely had the children in the stern due to their safety conscious nature. This information has been incorporated into RYA powerboat training since 2011 following a series of injuries.
MAIB Praised the Bystanders
MAIB identifies several individuals onsite by where they were or by their profession and thanks them for their quick response and assistance they rendered the Milligans, including those who called the accident into authorities.
We too commend those onsite that responded. A few months back we created a post trying to thank the thousands of first responders around the world that have helped with countless boat propeller accidents. In that post, Tribute to Rescuers, we singled out an instance in each of several categories. We chose Charlie Toogood, who leaped into the Milligan’s boat from another motorboat, as one of those examples.
Actions Taken by Other Organizations
While MAIB issued a bulletin on the use of kill cords shortly after the accident, MAIB recognized several other organizations that have taken actions in response to the Milligan accident as well.
RYA published safety articles in its magazine and launched a safety campaign at the London Boat Show in January 2014. RYA also produced some clips on YouTube and held some safety talks at the Southhampton Boat Shown in September 2013. RYA also produced some stickers encouraging kill cord use.
The British Marine Federation briefed boat retailers and Brokers Associations about the accident, and began work on a handover checklist for boat owners.
Devon and Cornwall Local Resilience Forum reviewed the emergency response to this accident and agreed to notify harbor authorities early on in the process in the future, and future emergency responses will try to avoid some of the location confusion surrounding this one (where the victims were to be picked up).
While MAIB did not mention them, we would commend RIB and Powerboat magazine for providing free warning stickers to their subscribers encouraging them to use kill cords, and to all the online boating forums that helped spread information about this accident and joined in the kill cord discussion, especially RIB.net. Additionally, Heddon Johnson rejoined the propeller safety movement following this accident and became a major voice for change (mandatory use of kill cords).
We also commend another action not mentioned, BBC Inside Out South West’s Boat Kill Cord Investigative Report delivered very well by Samantha “Sam” Smith.
We covered the accident with multiple posts and responded with a printed History of the UK Propeller Safety Movement, and an Interactive Timeline of UK Boat Propeller Safety. We also visited several times with many of our contacts in the UK encouraging them to become involved in the evolving discussion there following the Milligan accident.
After losing a family member to a boat propeller, many families talk about how they hope knowledge of their loved one’s accident will help prevent others from facing similar circumstances. Here in the U.S., boat propeller accidents are not front page news and definitely not national media front page news. However, the UK national media exploded with coverage of the Milligan accident and the later debate about mandatory use of kill cords, and even the recent release of the MAIB report. We deeply thank them for raising the awareness of these issues (hazards of boat propellers, need to wear kill cords).
Similarly, we appreciate the hundreds and hundreds of hours MAIB put into this investigation and producing the report. We find it a bit odd they do not look more widely for potential solutions (virtual lanyards). Autotether and Virtual Lifeline have both enjoyed some success in the market place.
MAIB openly states the report is not to asses blame, but it seems like there would be some harsher language addressed at boat builders and oversight organizations for allowing a boat with those known handling issues to be marketed the general public with large outboard engines.
Absolutely no mention was made of propeller guards or of systems to detect unmanned circling boats and shut them down, such as we described earlier.
Shortly after the accident, there was wide debate in online boating forums with strong ties to the UK about mandatory wear of kill cords and how many lives that might save. Nobody had any data on the number of similar accidents, we responded by listing some of them, now 9 months later MAIB says they identified 21 similar circling boat accidents beginning in 2005 one of them resulting in 7 fatalities and 12 injuries. It would have been great to have been able to access that information earlier.
No national boating accident database exists in the UK. Boat accidents do not even have to be reported. While U.S. Coast Guard’s Boating Accident Report Database (BARD) has plenty of problems, it is a great first stop when trying to identify similar accidents and beginning to get a handle on what contributes to those accidents. UK needs a similar database that is open to the public. We strongly encourage the UK to follow U.S. Coast Guard’s lead.
We also note the absence of mention of the coroners inquest in the Hutton accident in which the Coroner for the Isle of Wight called for promoting propeller safety and awareness.
The entire MAIB report reads a bit like they set out to try to encourage as much noise and activity around encouraging the use of boat kill cords they could, but they fail to mention the ongoing debate in the UK over mandatory use.
Our earlier tribute to first responders mentioned some thoughts for encouraging those with medical and related skill to spend more personal time on or near the water. Having some trained first responders on site helped prevent even more fatalities in this accident. We encourage MAIB to give that concept some though as well.
Thanks again to MAIB for all their work on this report and condolences to the Milligan family as they try to put their lives back together without Nicholas and Emily.