Haverfordwest paddleboard deaths - MAIB report published

[Telstar26]

Report here - a sad story

I am surprised at how few SUP users wear buoyancy aids - in that group, 4 of the 9 didn't wear them, including both leaders. That would be unthinkable for dinghy sailors - so why hasn't the message got through to paddleboarders?

Having said that, 3 of the 4 who died were wearing PFDs.

 

[WoodyP]

I think prosecution will follow. It's pretty damning.

 

[Telstar26]

I think prosecution will follow. It's pretty damning.

Yes. From para 1.5.4 (p21):

The (leader*) had not produced written risk assessments for the Pembrokeshire Tour and there were no indications that either leader was aware of the scale of the hazard posed by the weir, the implications of the height of tide, or the NRW flood* alert that was in force for the Western Cleddau. They had not assessed the competency of tour members who had not been previous customers of the (company*)and the participants were not required to complete a legal disclaimer, medical declarations, or provide emergency contact details before starting the tour.

* I've removed the name of the organising company, and corrected "food" to "flood"

 

[DFL1010]

I think prosecution will follow. It's pretty damning.

Minor point of order, an MAIB report is inadmissible in court (see page 2 of the report). Of course, if the police have/had a parallel investigation for a potential prosecution then that's a different story.

Also, and I'm aware I'm straying outside my area of expertise here, I was under the impression that in cases where there is potential for prosecutions, MAIB reports would be held back in order to not influence the jury pool - for sure this will be reported in the local papers, if not the national ones.

 

[ylop]

Report here - a sad story

I am surprised at how few SUP users wear buoyancy aids - in that group, 4 of the 9 didn't wear them, including both leaders. That would be unthinkable for dinghy sailors - so why hasn't the message got through to paddleboarders?

Having said that, 3 of the 4 who died were wearing PFDs.

I’ve not read the report yet but your comment about dinghy sailors - compare to windsurfers where outside of formal instruction they often don’t wear Bouyancy aids, and surfers who don’t at all. That, in part, is because they are tethered to a floaty board and often have a group around them. I suspect a bunch of other factors also contribute - like fashion, imagery in the media, where people first start etc. I do wear a Bouyancy aid on a sup but I think it may be too simplistic a solution to the problem - without reading the report Id not have been supping there on that day regardless.

 

[Wansworth]

Life jackets are not sexy,destroys the image of free,relaxed padddling

 

[penfold]

Drowning isn't sexy either.

 

[Wansworth]

Drowning isn't sexy either.

Many ofthe users are probably not sailers bit like drivers of those jet ski thingys

 

[TwoFish]

I am surprised at how few SUP users wear buoyancy aids - in that group, 4 of the 9 didn't wear them, including both leaders. That would be unthinkable for dinghy sailors - so why hasn't the message got through to paddleboarders?

Normally because they're attached by leash to around 200 litres of easy-to-grab buoyancy.

The physics obviously change where fast moving waters, weirs, drains, snag hazards etc. are involved. Then a buoyancy aid and a quick-release waist (not ankle) leash might be a really good idea.

 

[ylop]

Drowning isn't sexy either.

But before anyone gets too excited about whether they were wearing buoyancy aids or not:
- 9 people went paddle boarding, 5 with PFDs on and 4 without
- 4 people died, 3 with PFDs on 1 without

Whilst it would be quite a leap to suggest PFDs reduced their chance of survival, it is clearly misplaced to suggest that this was the basic problem. Similarly they make a big point about the fact they were not wearing quick release waist leashes (which could have been a contributing factor) but then describe that none of the victims were attached to their boards when recovered from the water - suggesting that despite the harder to release ankle leash either they or the conditions had broken them free. The MAIB does highlight that too much bouyancy can actually be a problem but provides no analysis whether that was a factor in the 3 people who died with PFDs on.

As with all MAIB report there are bits I read and think, "what are they getting at there?". On this occasion "the participants were not required to complete a legal disclaimer" like that would in some way have made things better! I think they are getting at the lack of formal paperwork but it wrongly implies that good risk management must be paperwork based or that there is any value (legal or otherwise) in disclaimers. These sort of things suggest to me that the MAIB aren't really the right people to do investigations - its very different understanding why a ship capsized or two ships collided from being realistic about how recreational water users on a river behave or even how the culture in outdoor activity centres works.

Ultimately I think there is a lack of structure around paddleboard guiding etc and that criticism is well placed, but I'm not sure the MAIB actually understand the problem. If the instructions did a flat water paddleboard instructors course and "did not have the training or experience to recognise, and so avoid, a dangerous weir" then the problem is that the qualifications they did get didn't teach them their limitations not that that nobody knows who the NGB for paddleboarding is. What the MAIB don't mention is that if it had been a sport with a "better" NGB (say kayaking), then for an adult trip it would still have been no more formally regulated and the participant would need to understand the sport well enough to know if the qualifications the guides purported to have were suitable and appropriate for the area in question.

I do find it astonishing that a paid paddleboard trip on a river was not insisting on PFDs and not using waist leashes, if it was a group of friends who had each reached their own risk assessment then it may be different. I guess the fact the organiser was (as the time) a police office and RNLI volunteer makes those fairly standard precautions all the more surprising (and she'd have been able to sell / rent waist leashes from the shop!). I'm not sure if the waters are muddier (excuse the pun) because they provided a kit list and then didn't insist on it or that might be seen as recommendations that let adults make up their own mind.

 

[MisterBaxter]

I haven't read the report but I know the river at Haverfordwest. When it rains in West Wales, it really rains, and the river changes entirely in character, becoming deep, fast and turbulent, between high concrete embankments. I can't see how anyone with any level of experience around rivers would think it a good idea to launch a SUP in those conditions, let alone lead a group of beginners.

 

[Resolution]

Having just read the report, I found the emphasis on regulation of SUP activities pretty irrelevant. Similarly, comments on PFDs and leashes seem overplayed when you look at the lack of correlation between what the survivors had and what the deceased had. To me the most informative part of the report related to tidal weirs and the varying levels of danger. The diagrams and dangers were eye-opening.

So what can be done to reduce the risks? Maybe when building (or servicing) a tidal weir a decent hydraulic engineer could build in a shape that would redirect the circular back flow into a spiral that would shoot out objects instead of trapping them?

 

[mjcoon]

But before anyone gets too excited about whether they were wearing buoyancy aids or not:
- 9 people went paddle boarding, 5 with PFDs on and 4 without
- 4 people died, 3 with PFDs on 1 without

Whilst it would be quite a leap to suggest PFDs reduced their chance of survival, it is clearly misplaced to suggest that this was the basic problem. Similarly they make a big point about the fact they were not wearing quick release waist leashes (which could have been a contributing factor) but then describe that none of the victims were attached to their boards when recovered from the water - suggesting that despite the harder to release ankle leash either they or the conditions had broken them free. The MAIB does highlight that too much buoyancy can actually be a problem but provides no analysis whether that was a factor in the 3 people who died with PFDs on.

As with all MAIB report there are bits I read and think, "what are they getting at there?". On this occasion "the participants were not required to complete a legal disclaimer" like that would in some way have made things better! I think they are getting at the lack of formal paperwork but it wrongly implies that good risk management must be paperwork based or that there is any value (legal or otherwise) in disclaimers. These sort of things suggest to me that the MAIB aren't really the right people to do investigations - its very different understanding why a ship capsized or two ships collided from being realistic about how recreational water users on a river behave or even how the culture in outdoor activity centres works.

Ultimately I think there is a lack of structure around paddleboard guiding etc and that criticism is well placed, but I'm not sure the MAIB actually understand the problem. If the instructions did a flat water paddleboard instructors course and "did not have the training or experience to recognise, and so avoid, a dangerous weir" then the problem is that the qualifications they did get didn't teach them their limitations not that that nobody knows who the NGB for paddleboarding is. What the MAIB don't mention is that if it had been a sport with a "better" NGB (say kayaking), then for an adult trip it would still have been no more formally regulated and the participant would need to understand the sport well enough to know if the qualifications the guides purported to have were suitable and appropriate for the area in question.

I do find it astonishing that a paid paddleboard trip on a river was not insisting on PFDs and not using waist leashes, if it was a group of friends who had each reached their own risk assessment then it may be different. I guess the fact the organiser was (as the time) a police office and RNLI volunteer makes those fairly standard precautions all the more surprising (and she'd have been able to sell / rent waist leashes from the shop!). I'm not sure if the waters are muddier (excuse the pun) because they provided a kit list and then didn't insist on it or that might be seen as recommendations that let adults make up their own mind.

Surely the relevance of lack of paperwork is that it implies a casual attitude to safety. Maybe that is the same as "lack of structure". Conversely a rigorous tick-box attitude to risk assessment can lead to an equally casual attitude, of course.

 

[Stemar]

If the instructions did a flat water paddleboard instructors course and "did not have the training or experience to recognise, and so avoid, a dangerous weir" then the problem is that the qualifications they did get didn't teach them their limitations

ISTM that this is crux of the problem. Even a basic course should at least discuss weirs and how dangerous they can be. Did it? Unfortunately, in every learning curve, there is a point when one thinks one knows more than one does, and sometimes it bites.

 

[dankilb]

I’m an ASI Level 2 SUP instructor (as well as a SLSGB beach lifeguard). Not currently practicing, not a big part of my life/identity, and the background to which is a longer story - so I don’t have a strong position on the burgeoning SUP industry and won’t be spreading (or receiving!) any vitriol in that context.

I’ve read the report closely (having followed the incident from the start) and am still processing the content and implications…

But on the qualifications point - yes, the 2 or 3 day courses are ‘minimal’. Taught and assessed properly, they can still safely cover the basics for the remit of operation.

However, there’s no question that fast flowing rivers are outside of the operating environment remit for any ‘level 1/2’ SUP qualification from any of the bodies/NGBs.

You are clearly trained for (and given written materials stating…) where you can operate and flowing rivers with weirs definitely are not included. It may be possible to qualify to operate a river tour - in benign conditions - but I’d imagine very few instructors/centres in the UK would hold this level of qual.

I don’t know much about ‘WSA’ (a private training/awarding body) - but their courses should make clear where you can operate.

I’d have to check my files to refer exactly to the definition of ‘enclosed water’ I was trained to operate in.

I know it’s no revelation - but put simply, my point is they shouldn’t have been there and in their training they would’ve been told this.

Should weirs feature in entry level watersports qualifications (that explicitly don’t qualify you to operate near/around them)? I cannot answer. But I’m sure this incident will be used as a sobering learning example for water/outdoor/adventure-sport coaching, guiding and instructing in the future.

 

[MisterBaxter]

So what can be done to reduce the risks? Maybe when building (or servicing) a tidal weir a decent hydraulic engineer could build in a shape that would redirect the circular back flow into a spiral that would shoot out objects instead of trapping them?

I think it's just basic water safety - a Welsh river in flood isn't a safe place for anyone who isn't experienced and using a suitable craft, eg an appropriate kayak with spray deck, helmet, buoyancy aid, wetsuit etc.

 

[Wansworth]

We live In an age where common sense has been replaced with a certificate and as time passes there will be a need for much more control as people who can auto regulate their behavior gets less.

 

[RivalRedwing]

We live In an age where common sense has been replaced with a certificate and as time passes there will be a need for much more control as people who can auto regulate their behavior gets less.

like that in kayaking too... I always shied away from anyone who introduced themselves as a 'senior instructor' as opposed to demonstrating their competence through actions (with relevant paperwork out of sight in the proverbial back pocket)

 

[ylop]

ISTM that this is crux of the problem. Even a basic course should at least discuss weirs and how dangerous they can be. Did it?

I've never done any SUP instructor training, but I have done a SUP course and a SUP tour that included instruction. Both covered all the sort of safety stuff you would expect (including pro's/con's of different leashes). Neither mentioned weirs at all - probably because it would be so far from the sort of SUPping we were doing or they would expect us to do. (I expect they might feel it necessary now; neither has anyone ever provided me with any training how to know if my guide/leader has the experience/competence to go on a particular trip - but that applies to sailing, powerboating, canoeing, rock climbing, mountain biking etc too).

However, there’s no question that fast flowing rivers are outside of the operating environment remit for any ‘level 1/2’ SUP qualification from any of the bodies/NGBs.

I'm not disputing that but does everyone agree what fast flowing means? can a stretch of river be "in scope" depending on conditions and out of scope on other days? Does the training teach you where to find information about river depths and flows?

You are clearly trained for (and given written materials stating…) where you can operate and flowing rivers with weirs definitely are not included. It may be possible to qualify to operate a river tour - in benign conditions - but I’d imagine very few instructors/centres in the UK would hold this level of qual.

BCU offer a white water SUP instructor/coach qualification. They seem like the logical NGB for that given that a kayak would be a sensible craft for those conditions.

I don’t know much about ‘WSA’ (a private training/awarding body) - but their courses should make clear where you can operate.
I’d have to check my files to refer exactly to the definition of ‘enclosed water’ I was trained to operate in.

I've just had a browse of the WSA SUP instructor pathways - the pre course information certainly makes clear the limitations - did it then? I'm not suggesting that the leader(s) were faultless but organisations (commercial or otherwise) that offer qualifications should be thinking carefully what they say or imply they equip you to do.

I know it’s no revelation - but put simply, my point is they shouldn’t have been there and in their training they would’ve been told this.

But you acknowledge that: 1. You don't actually know what the relevant content of the WSA training syllabus was at the time; 2. You can't possibly know whether they actually were told this in their training (being on the syllabus and actually being covered on an individual course are not the same thing!).

I think it's just basic water safety - a Welsh river in flood isn't a safe place for anyone who isn't experienced and using a suitable craft, eg an appropriate kayak with spray deck, helmet, buoyancy aid, wetsuit etc.

I'm very much with you. I guess if it goes to trial we might learn how much of this was obvious and how much was brushed over or dismissed by those involved.

 

[ylop]

We live In an age where common sense has been replaced with a certificate and as time passes there will be a need for much more control as people who can auto regulate their behavior gets less.

I think you are probably wrong. Common sense (or what should probably be better described as good judgement) has never been ubiquitous. People have always done stupid stuff, mostly they get lucky and nothing too serious happens. However tragic incidents have happened pretty much throughout human recreational activity and its easy to look at most of them afterwards and say well that was stupid. I actually think certificates and qualifications can reduce the risk provided: (1) its clear what certificate / qualification you need to do a particular task; (2) there's a genuinely robust testing framework to ensure people me the standards; (3) there's continuing oversight after qualification to ensure that the person is still operating within the scope of the certificate. When governments don't get 1,2,3 right usually insurers defacto regulate this stuff. The only thing that has changed in the "age we live in" is that its more likely that someone guiding/instructing will be getting paid for it - but that should make it more likely that there is an insurer and/or professional body overseeing it.