Haverfordwest paddleboard deaths - MAIB report published

[Wansworth]

I was relating to my own experience working at a sailing school in the 1970s.An instant was theafternoon was pencilledin for taking 5 learners out in. Wayfarer.Onceon the water the strong wind was obvious and inappropriate for teaching in crowded waters of Bosham so I declinedto raise sail against the instructions of the chief instructor……..events proved me correct as soon after setting sail the other boat returned,Ihad no Qualifications but made the decision based on my sailing experience……or maritime common sense

 

[Capt Popeye]

I was relating to my own experience working at a sailing school in the 1970s.An instant was theafternoon was pencilledin for taking 5 learners out in. Wayfarer.Onceon the water the strong wind was obvious and inappropriate for teaching in crowded waters of Bosham so I declinedto raise sail against the instructions of the chief instructor……..events proved me correct as soon after setting sail the other boat returned,Ihad no Qualifications but made the decision based on my sailing experience……or maritime common sense

Yes I quite agree ; and yes Common Sense should warn boaters of the impending danger , thats if they have aquired a Afloat Common Sense from being famiar to small boat boating upon rivers and seas , maybe the Paddle Boarders are generally NOT aquainted with boating i general , but went straight into Paddle Boarding , bypassing the learning curve that would be aquired from generally messing about in boats
Down ere on the river Teign , we have lots of Paddle Boarders , on the Sea Front , (main Beach) , on the River Beach (Back Beach plus up river ; A certain Club sometimes organises PB with a sort of coaching , providing safety I guess by way numbers , they have been making enquiries to organise PB in the Estuary amoungst the Yachts and Shipping ; I hope that the Harbour Authority ban PB in these areas , as its plainly not safe environment to do so ; so we will see !

 

[ylop]

I was relating to my own experience working at a sailing school in the 1970s.An instant was theafternoon was pencilledin for taking 5 learners out in. Wayfarer.Onceon the water the strong wind was obvious and inappropriate for teaching in crowded waters of Bosham so I declinedto raise sail against the instructions of the chief instructor……..events proved me correct as soon after setting sail the other boat returned,Ihad no Qualifications but made the decision based on my sailing experience……or maritime common sense

I'm not sure your experience in the 1970s translates to "we live in an age"... your 40+ year old anecdote could have been this year or 40 years earlier.

Yes I quite agree ; and yes Common Sense should warn boaters of the impending danger , thats if they have aquired a Afloat Common Sense from being famiar to small boat boating upon rivers and seas , maybe the Paddle Boarders are generally NOT aquainted with boating i general , but went straight into Paddle Boarding , bypassing the learning curve that would be aquired from generally messing about in boats

Popeye - the experience of the instructors etc is discussed in the report. You should read it rather than speculating. I wouldn't assume that "messing about itn boats" is a good way to understand weirs and the risk the pose anyway.

Down ere on the river Teign , we have lots of Paddle Boarders , on the Sea Front , (main Beach) , on the River Beach (Back Beach plus up river ; A certain Club sometimes organises PB with a sort of coaching , providing safety I guess by way numbers , they have been making enquiries to organise PB in the Estuary amoungst the Yachts and Shipping ; I hope that the Harbour Authority ban PB in these areas , as its plainly not safe environment to do so ; so we will see !

its a dangerous path to go down encouraging the HA to ban any particular type of water user. If SUPs are unsafe then what about seakayays? if sea kayaks are unsafe are dinghy tenders? Perhaps motorised tenders are OK but sailing dinghies are too unpredictable? If a yacht can't avoid a PB in an estuary I'm not sure the boat or skipper is fit to be at sea either!

 

[dankilb]

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.

Yes, but… It was clear from the report that the local kayak club never traverse the weir - regardless of kit/experience - unless with considerable and codified extra safety measures in place (I’d have to re-read, which I can’t now, but they cited what those were).

 

[westernman]

Weirs are very often extremely dangerous.
You should never attempt to go across one in any craft whatsoever without having checked it out minutes before trying to cross it.

Anyone who had looked at it on the day could have told you not to go near it.

The leaders had not checked it out. This is by far the most (and in my view the only) important failing.

 

[dankilb]

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?

Good qu. I couldn’t answer - based on my recollection of the training - but then my intention was only ever to operate in ‘salty’ conditions (and they did give good details for that - quantifying precise distances from shore/depths/tidal conditions etc.). I would have to check the ASI materials I was given before answering categorically

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.

Agreed - as a trainer, you have to cover the safety bases first and foremost. I think I received very good SUP instructor training (from a former Team GB kayaker, sports science lecturer and watersports business owner). This is judged based on other ‘high risk’ activities I’ve sought quals in (inc. YM and also EASA/CAA PPL). But they made it clear that there wasn’t time (in 2 days for Level 1) to train us how to coach SUP. They explicitly said the time would be used, instead, to cover how to operate safely (with strong emphasis on risk of death, criminal negligence, ‘you don’t want to end up in the coroners court’ etc.). It’s not easy for trainers to set this sort of tone. Half of our cohort ‘failed’ the course! Anecdotally, I’ve since learned that’s pretty unheard of. Perhaps I was lucky in that regard?

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 do/I can’t. I supposed this could be investigated (witnesses on the course etc.). But perhaps they were so far outside of SOPs/remit that the investigation didn’t consider the nuances of the training? (I’m not commenting on why/how they found themselves there). As I said above, any ‘witness‘ on the course I was on would have attested to the instructor banging on about this above all else (after all, they are assessing you for a particular level/activity - so a strong focus on the scope of that seemed logical to me at the time).

 

[mjcoon]

Weirs are very often extremely dangerous.
You should never attempt to go across one in any craft whatsoever without having checked it out minutes before trying to cross it.

Not to contradict, but...
I was an undergraduate in Cardiff in early 1960s. Someone cooked up the idea of a raft race for Rag Week along the Taff. Some of my mates took part but as a non-swimmer I stuck to photographer. One of my shots of their raft balanced on a weir looked like an action shot and was commended as such. But actually they were stuck there for some time trying to get the raft across... "Health and Safety"; what's that?

 

[ylop]

Although the MAIB don’t directly make this point, I think what they are indirectly getting at is it’s hardly surprising if the SUP training that has originate from the surf branch of the sport (which was its origin) doesn’t make any reference to weirs etc. In that area the BCU are much more relevant.

Half of our cohort ‘failed’ the course! Anecdotally, I’ve since learned that’s pretty unheard of.

That is reassuring to see. I hear of so many sports instructor courses where everyone passes or maybe one in eight has to do a little bit extra the next weekend or delivers a couple of supervised sessions and is suddenly competent.

the explosion of SUP means there can’t really be enough people who genuinely have the depth of expertise to train more than the basic levels. i suspect that so many people are self taught sup (or perhaps a 30 minute taster - then what’s left to learn ;-) ) and so will perceive that anyone who is a sup instructor is obviously an expert in supping. It’s a real issue for the novice looking for a guide.

 

[Jodel]

1.5.4 of the report shows the conditions at the weir during the recce which seem relatively benign. Did the main leader forget to check the tide tables and got caught out? From upstream it is near enough impossible to see the drop on the other side of a weir until it is too late.

 

[Capt Popeye]

I'm not sure your experience in the 1970s translates to "we live in an age"... your 40+ year old anecdote could have been this year or 40 years earlier.

Popeye - the experience of the instructors etc is discussed in the report. You should read it rather than speculating. I wouldn't assume that "messing about itn boats" is a good way to understand weirs and the risk the pose anyway.

its a dangerous path to go down encouraging the HA to ban any particular type of water user. If SUPs are unsafe then what about seakayays? if sea kayaks are unsafe are dinghy tenders? Perhaps motorised tenders are OK but sailing dinghies are too unpredictable? If a yacht can't avoid a PB in an estuary I'm not sure the boat or skipper is fit to be at sea either!

Well you state that its a dangerous path for HA to ban any particular type of water user , eh - well our HA ban Jet Skis etc from using the Harbour , except for from Launching directly to harbour mouth ; There is a speed limit of 6knots everywhere in the river Teign up to the end of realistic navigation (10 miles up river) , so speed boats are banned or restricted , (except to members of a Ski Club who have a certain area desiugnated for them) , so we already have restrictions from the HA ; my observation that PB /SUP re restricted to certain parts of the River are based upon experience on the tidal thames , where it was usuall to have fatalities each season from single scullers coliding with mooreds up 80ft lighters , thgese scullers had rowed directly into and under the barge bow which had a large angula overhang ; fatalities occured when the sculler , by now in the water , attempting to swim away from the barge bow , loosing strength etc , then getting drawn underneath the 80ft barge , eventually emerging , drowned , af the aft end on the barge ; thats the possible liklyhood I see happening to any PB who looses control or balance , then getting sucked /drawn by the strong currents under or between moored Ships ; once under or between two ships the PB /SUP is really unable to escape from a death trap , I think ; as in that possition I cannot see any one being able to access them to save them

Its not a happening that I would be happy to see or hear about ; hence the need for HA safety rules

 

[ylop]

popeye - so jetski aren’t banned (just not allowed to play around); waterskiing is actively permitted in sensible areas and powerboats are speed limits keep people safe — management is not banning.

experience on the tidal thames , where it was usuall to have fatalities each season from single scullers coliding

you got data to back that up? I’m not saying it never happens but USUAL

 

[Adios]

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

Having fallen off one a few times in quick succession I can say they are not that easy to remount when tired and you get tired doing it. They are harder to remount when wearing a PFD ironically but i'd still rather have one. But you'd need a next level life jacket to save you in a weir in flood like that anyway so its a mute point as most of the deceased found out

1.5.4 of the report shows the conditions at the weir during the recce which seem relatively benign. Did the main leader forget to check the tide tables and got caught out? From upstream it is near enough impossible to see the drop on the other side of a weir until it is too late.

the recce was in the middle of August in a dry spell, no one with even a slight bit of sense recces a river months in advance,


They provide a video of the river on the day of the event clearly in flood, look at the water height at the bridge arches and very clear speed of flow.

all this below is really beyond belief. Both of them should have easily known better from their previous life and work experience regardless of any SUP training. I don't think the answer is more SUP training as you can't train someone out of being that much of an idiot. I mean if they hadn't learnt by then they'll never learn (until its too late like this). All more regulation and forced training will end up doing is creating more expense and hassle for people who wouldn't be such idiots anyway.


Obviously they shouldn't have risked it anyway in those conditions if they'd actually checked what the conditions were . But it seems to me big part of the problem was not discussing how to negotiate the weir. The leader and one behind went down the middle fish pass which will have been visible from upstream but quite subtly so. If they had been given clear instructions on what to look for they could have all done that and been fine. Instead she's alright jack and the others are randomly either side going over the drop and getting in the boil.

 

[Capt Popeye]

Well having now read up on another account of this incidet , the local riverside , launching site , riverside signage comes in for improovement suggestions ; including perhaps a sign stating that the RNLI do not provide rescue effort on that part of the river

Also there is mention that the Weirs danger signage is perhaps not adequate for purpose

I understand that the Company Tour Leader was arrested by the Police and is still under investigation

 

[Adios]

Well having now read up on another account of this incidet , the local riverside , launching site , riverside signage comes in for improovement suggestions ; including perhaps a sign stating that the RNLI do not provide rescue effort on that part of the river

Also there is mention that the Weirs danger signage is perhaps not adequate for purpose

I understand that the Company Tour Leader is (or was) being restrained under police cusdody

They went over it in the recce when it was a tiny trickle but that day they would have heard the roar of the weir from a good way off, no need for signs, it was written all over the swirling water the whole day they were on the river and everything they went past. It should have been obviously different enough for them to know to get to the side and investigate. Staggering recklessness and stupidity. I'm usually on the side of "accidents happen" and not thinking they should throw the book at people but this case is extreme and I hope she gets a proper bit of time inside to reflect on it

 

[Capt Popeye]

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.

Well having found another report on utube its comments include the statement that the Boarders some wore ankle tethers and not waist tethers , so probably the Boarders were not able to release themselves from their boards once in the turbalant disturbed waters of the Weir . so guess that the boyancy of the boards was greater that the boyancy of life jackets etc ; plus them boards have great boyancy in them

The reports appear to recomend greater safety control and regulations for Boarding , which I would agree with

 

[Adios]

Well having found another report on utube its comments include the statement that the Boarders some wore ankle tethers and not waist tethers , so probably the Boarders were not able to release themselves from their boards once in the turbalant disturbed waters of the Weir . so guess that the boyancy of the boards was greater that the boyancy of life jackets etc ; plus them boards have great boyancy in them

The reports appear to recomend greater safety control and regulations for Boarding , which I would agree with

the report suggested the boards were pulling them back into the weir. They just shouldn't have been there and should have been able to read the conditions long before getting to the weir. Its simple to add a few minutes section to a SUP course entitled "weirs suck". Saying more regulation is often a too simplified broad brush answer to any incident when it might really not have prevented this. One of those killed was a trained canoeist so I think it was partly foolhardiness in carrying on as he should surely have known the river was high and known what the weird sound signified.

 

[ylop]

Well having found another report on utube its comments include the statement that the Boarders some wore ankle tethers and not waist tethers ,

So clearly you haven’t read the report in the opening link which includes all the detail you could really ever want on this. NONE of the paddlers were wearing quick release waist tethers. I’d suggest reading the full report before commenting further, wild speculation without bothering to read it is disrespectful to the four people who lost their lives - at least take the time to see what you can learn from it before shouting your conclusions. Anyone who believes there is NOTHING to learn here and they would have known better is missing the point. There is always something to learn - even if it is just that if you confidently lead others many will likely follow you without questioning your expertise.

 

[ylop]

One of those killed was a trained canoeist so I think it was partly foolhardiness in carrying on as he should surely have known the river was high and known what the weird sound signified.

She.
And to be clear she did beginner level canoe stuff 5+ yrs before (as a teenager) - which may well have been nowhere near a river. It may just be coincidence that she was the last person other than the instructor to go over or it may be she was holding back and since nobody signalled there was a problem followed on. I don’t know how close you would be to the weir before you were going over whether you wanted to or not.

However it has all the characteristics of the classic group decision making ”heuristic traps” which have been widely discussed in other outdoor pursuit incidents. I think saying that any of the paying participants should have perceived the risk misses the point of having a paid guide.

 

[steve yates]

Nothing to do with wearing a pfd. As an former white water kayaker, no pfd/lifejacket in the world will help you if you get caught out of your boat in a recirculating stopper wave, which all wiers produce with enough water volume. Having almost drowned in one once when I fluffed a turn, I can say that the only thing that saved me was actually unzipping the lifejacket and ditching it as I was dragged under for the third time. That gave me just enough less bouyancy to sink as far as the bottom where the current caught me and sucked me out.
No beginners should be anywhere near a weir on a flooding river, and I would actually guess that no paddleboarder at all should be shooting one. The chances of staying on the board must be extremely low.

 

[dankilb]

1.5.4 of the report shows the conditions at the weir during the recce which seem relatively benign. Did the main leader forget to check the tide tables and got caught out? From upstream it is near enough impossible to see the drop on the other side of a weir until it is too late.

I'd go a step further. In not checking/briefing for/considering the weir on the day, it was to all intents and purposes as if they forgot it was there altogether. In order to check something, you have to know be consciously aware of it in your planning/decision-making. There are a number of factors in the report that suggest the leaders were not actively considering the weir as a feature, let alone a risk/hazard, on the day:

• Not briefing the group or discussing the portage option
• Not inspecting the weir on the day - despite being only a few hundred metres away and just out of eyeshot at the location they chose when inspecting the river upstream:

• The leader 'shooting' the fish pass and not reporting their intentions with the group
• Figure 4 suggests they would have come across it quickly. And that's the view from the bridge - much higher than the deck of a SUP

Together, to me these factors suggest that when they came upon the weir after passing the bridge, this was pretty much the first anyone thought of it (as a risk - or perhaps as a feature, altogether?) on the day. It was therefore a long way from being 'on their radar' at the level of checking tides or other hydrographic info.

Then are various 'human factors' noted in the report that may have contributed to this oversight:

• Deceptively favourable conditions on the August recce - as Jodel cites
• The weir wasn't codified in any risk assessment/documents (nor even the WhatsApp group) that could've subsequently served to remind/inform...
• The logistics of the event (accommodation; transfers; mixed ability group, supplying own kit) putting extra demands on the capacity of the leaders
• Even the lack of a more 'appealing' alternative activity (the planned walk seems a 'thin' alternative to a commercial adventure/watersports activity - compared, say, to an alternative SUP activity in a genuinely enclosed or lifeguarded location) perhaps adding to the cognitive bias in favour of "go"

I'm not suggesting these are the only set of material or contributory factors, of course. But to me they speak to the difference in decision-making between knowing about a risk and failing to properly assess it - and, essentially, acting as if the risk is not there at all. I feel that both the content and the 'discourse' of the report (the factors the report authors choose to cite, even those - like the broader logistics of the activity - that weren't directly involved in the accident) suggest that the weir wasn't a feature - real or perceived - in terms of the situational awareness of the leaders (beyond the very early stages of planning) and therefore by extension of the group as a whole.

So, in essence, yes - by the time the group were upon the weir it was too late (both leaders and participants may as well have been looking at the hazard for the very first time a few metres away from it, in the middle of a fast flowing river). Sadly their fate was of course sealed from the point at which the activity was planned to traverse the weir at all. Given the time of year and all other factors, risk of injury or death was high from that decision onwards.