A woman fell from a Broads' cruiser and was fatally injured after failing to moor at Great Yarmouth yacht station because it was full.
Laura Louise Perry, 38, of City Walk, London, died following the incident on the River Bure on August 19, 2020.
The Marine Accident Investigation Branch (MAIB) has published its interim report into the tragedy which saw a fleet of emergency vehicles rush to the scene and roads closed for four hours.
It follows the chief inspector of marine accident's urgent recommendation in the months after her death to make several amendments to the hire boat code for the prevention of persons falling overboard, hire boat handover procedures, and engine control system design.
The report states the woman was aboard the motor cruiser Diamond Emblem 1, among a family group of nine people.
She fell overboard from the aft deck (at the rear) when the hire boat’s stern made "hard contact" with the embankment wall opposite the Great Yarmouth yacht station at around 1.18pm.
She was caught in the propeller and fatally injured.
It says that at the time of the accident, the motor cruiser was being manoeuvred to stop and turn in the river as the family group had intended to moor up at the yacht station, but it was full.
The family had travelled from the Stracey Arms to Great Yarmouth on a fine and sunny day as the tide ebbed.
The interim report has been published because the full report will not be completed within 12 months of the accident.
An inquest into Miss Perry's death has been adjourned until November 4.
MAIB says a draft report is nearing completion and will be distributed to stakeholders for a 30-day consultation period.
It says the investigation has considered all aspects of the accident, including the causes and circumstances of the hard contact, the boat construction standards for prevention of persons falling overboard, the handling of large dual control cruisers by hirers, and the hire boat induction and handover process.
Miss Perry was a mother to three boys aged four to 16.
A funeral notice said: "She treasured her boys and embraced every minute spent with them on a multitude of trips, adventures, holidays and ‘memory-making'. She loved them and, their father, James Allen, very deeply."
Play It Safe
The Eastern Daily Press and its sister papers, the North Norfolk News and Great Yarmouth Mercury, have launched the Play It Safe, Be Water Aware campaign to ensure visitors to Norfolk's waters stay safe.
David Powles, EDP editor, said: "Norfolk and Suffolk are blessed with some wonderful places to enjoy water, with miles and miles of stunning coastline and the beautiful Broads.
"In 2020 we sadly saw several tragedies both on the coast and inland and already this summer there has been one tragic death of a young man.
"We want to spread more awareness to those looking to enjoy our waters and hope this campaign will do just that, plus encouraging shopkeepers and businesses in popular areas to display our specially designed posters."
Our Play it Safe water safety posters can be purchased at www.norfolkstore.co.uk
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