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Accident investigators are calling for a tightening of procedures following the death of a 14-year-old sea cadet, who died after falling from the rigging of a sail training ship.
Jonathan Martin, from near Ashford in Kent, fell backwards more than 25ft, striking the side of the TS Royalist before falling into the sea, a Marine Accident Investigation Branch (MAIB) report said.
He was taken to hospital by coastguard helicopter but died due to the severity of his injuries.
He'd been assisting other cadets to stow the sails as the vessel was at anchor at Stokes Bay in Hampshire on May 2 last year.
The MAIB report said that Jonathan fell "because he unclipped his belt harness from the wire jackstay (to which the edge of a sail is fastened) provided on the fore course yard, contrary to his training and onboard procedures for work at that position".
But the MAIB added that its investigation had "highlighted concerns regarding the supervision of the cadets when aloft on the vessel's masts and rigging, and the suitability of the belt harnesses provided."
The MAIB went on:
"Recommendations have been made to the Marine Society & Sea Cadets (MSSC) and the Royal Navy aimed at improving the safety of cadets by addressing the safety issues identified and, through the development of assurance procedures, to ensure that the risks to cadets participating in this challenging, but potentially dangerous activity, are reduced to and kept as low as reasonably practicable."
The report said that the MSSC withdrew TS Royalist from service in September 2010 for refit, and pending a review of the equipment and procedures used by cadets when aloft.
It has also continued to investigate the provision of a suitable replacement harness and is progressing the development of a safety management system for its offshore operations.