Haverfordwest paddleboard deaths - MAIB report published

ylop

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She pleaded guilty to manslaughter today, will be sentenced next month,
What exactly was the cause of death? They got caught in a strong back eddy and got held under and drowned?


Can someone link the MAIB report again? I can't find it on the MAIB page and the original link is broken.

Marine Accident Investigation Branch reports
Its disappeared. My guess is that it was been pulled whilst proceedings were live to prevent any sub-judice issues?
 

ProMariner

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It is deeply saddening and a waste of life to lose so many individuals in this tragic incident. My thoughts and prayers are with their families, who will never be the same again.

I would like to express my sincere gratitude to all the instructors, group leaders and keen enthusiasts who dedicated their time and effort to teaching me paddle boarding, kayaking, dinghy sailing, cruising, racing and all the other outdoor hobbies and sports that have made the world a richer place.

It is important to note that none of these individuals were driven by power or money. They simply shared their love for the outdoors and its many bounties.

While life is not always risk-free, we must consider the potential consequences of attempting to eliminate all risks. I may not be an adrenaline junkie, but I believe that most worthwhile endeavours involve some degree of risk, and personal judgment regarding its magnitude. We all have to start somewhere, and there will always be accidents and pioneers pushing the boundaries of what is possible and what is not.

The group leaders in this incident appear to be public-spirited individuals dedicated to making life richer for others. I understand the immense pain and loss they have already endured, and I hope that the judge will impose only the lightest penalty. We would not want to live in a world where we felt the risk of taking our friend for a sail, walk, or paddle exceeded the joy written on their face they experienced upon completion.
 
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RivalRedwing

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While life is not always risk-free, we must consider the potential consequences of attempting to eliminate all risks. While I may not be an adrenaline junkie, I believe that most worthwhile endeavours involve some degree of risk, and personal judgment regarding its magnitude. We all have to start somewhere, and there will always be accidents and pioneers pushing the boundaries of what is possible and what is not.

The group leaders in this incident appear to be public-spirited individuals dedicated to making life richer for others. I understand the immense pain and loss they have already endured, and I hope that the judge will impose only the lightest penalty. We would not want to live in a world where we felt the risk of taking our friend for a sail, walk, or paddle exceeded the joy written on their face they experienced upon completion.
oh brother.. if you are a leader of an inexperienced group you do not push boundaries; if you want to push boundaries then do it with like minded experienced people who fully understand the risks...
 

RunAgroundHard

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I am not sure that “public-spirited” is the best descriptor, as the organisation took fees from clients and paid instructors to deliver the service. A totally different scenario to friends and family enjoying an outdoor activity together.
 

Stemar

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While life is not always risk-free, we must consider the potential consequences of attempting to eliminate all risks.
I absolutely agree. However, while taking people on a trip that is not entirely risk-free, it behoves those public-spirited individuals to consider the risks and, when they are excessive, to minimise them or, where that isn't possible, to cancel the trip.

I haven't examined the case closely but, from what I gather, the risk assessment was non-existent, and they took beginners out in conditions that a cursory glance would have made any sensible leader cancel the trip. I'm no fan of blame culture, but I do think in this case, the manslaughter conviction was entirely justified.
 

ProMariner

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oh brother.. if you are a leader of an inexperienced group you do not push boundaries; if you want to push boundaries then do it with like minded experienced people who fully understand the risks...
The trouble with any outdoor sport, is often the boundaries are unclear and constantly changing, what's fine one minute can become risky in the blink of an eye. Consider that nice sail with friends which quickly turns into a battle with a white squall. Or that easy hill walk route you've done a hundred times where the visibility dropped down to two meters, and the stream you were planning crossing was a river when you arrived. Every sport and pastime will have similar parallels.

Am not disputing that a bit more training, experience and flexibility of planning would have been appropriate in this circumstance.
 
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MisterBaxter

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I know that river and when it's high after heavy rain, you know it at a glance - a serious weight of water moving past you, with a lot of very visible surface turbulence, eddies and general signs of danger. I can only assume that inexperience was the root cause - I can't believe that anyone with proper experience around rivers would have thought it safe.
More broadly, paddleboards are a lovely easy way to get on the water but I do worry that their accessibility for people who don't have much experience on the water makes them a danger. But I don't know what the stats are like for paddleboard accidents, maybe in reality they are fine - electric scooters look like death traps to me but apparently there's no clear evidence that they're more dangerous than bicycles.
 

RivalRedwing

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The trouble with any outdoor sport, is often the boundaries are unclear and constantly changing, what's fine one minute can become risky in the blink of an eye. Consider that nice sail with friends which quickly turns into a battle with a white squall. Or that easy hill walk route you've done a hundred times where the visibility dropped down to two meters, and the stream you were planning crossing was a river when you arrived. Every sport and pastime will have similar parallels.

Am not disputing that a bit more training, experience and flexibility of planning would have been appropriate in this circumstance.
It was a paid for activity with monies going to an organization that should have behaved in a professional manner, they didn't and customers died... accidents happen but this one should not have occurred.
 

RunAgroundHard

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… we must consider the potential consequences of attempting to eliminate all risks. …

This is a common misconception that risk management is attempting to eliminate all risk. Risk engineering never strives to eliminate all risk, a probability of zero, but understands that reducing risk to an acceptable level is a reasonable, possible and likely outcome if managed. What controls will be put in place, and how the strength of those controls is determined will be based on the tolerability of the consequences. There are epic failures in risk engineering, Fukushima being a good example. The risk of a tidal was considered and barriers built into the design, but the magnitude of the tidal wave was underestimated, even though statistical models existed to show bigger waves were probable over the life of the plant. The probability happened and the barriers were overwhelmed.

The point is, tolerance of risk consequences is understood. In the case of the paddle board incident all the information was available to create a risk management plan and implementation it. Unfortunately skills in developing risk management plans and implementation of them is dire if no training has been given. Risk management should make a business more profitable, allow the activities to be performed and protect the business or organization from loss, however you wish to define loss ( life, injury, reduced profit, overhead).

No one should be thinking that all risks need to be eliminated if being tasked to develop a risk management plan. If they do, they are incompetent to perform the job.
 

Marsali_1

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The trouble with any outdoor sport, is often the boundaries are unclear and constantly changing, what's fine one minute can become risky in the blink of an eye. Consider that nice sail with friends which quickly turns into a battle with a white squall. Or that easy hill walk route you've done a hundred times where the visibility dropped down to two meters, and the stream you were planning crossing was a river when you arrived. Every sport and pastime will have similar parallels.

Am not disputing that a bit more training, experience and flexibility of planning would have been appropriate in this circumstance.
While I think I understand your feelings with respect to the motivations of "...public spirited individuals..." when it comes to sharing the beauty and benefits of outdoor activities, I am having some difficulty with your thoughts in the following, "... life is not always risk-free, we must consider the potential consequences of attempting to eliminate all risks. I may not be an adrenaline junkie, but I believe that most worthwhile endeavours involve some degree of risk, and personal judgment regarding its magnitude. We all have to start somewhere, and there will always be accidents and pioneers pushing the boundaries of what is possible and what is not...."

On the one hand, everything you state in that quote is perfectly valid in the case of an individual person doing some activity on their own. But it gets more complex when that same individual engages in the same activity under the leadership of another more experienced individual. The first individual still assumes some level of risk associated with engaging in the activity but the leader, by virtue of being the leader, also assumes risk and a duty of care for the first individual as well as for themself.

When payment for services is involved, as was the case in this tragedy, then the responsibilities of the leader increase dramatically. The individual participant still has to accept some level of risk, but it is incumbant upon the leader to fully understand and explain those risks involved and mitigate them as best as possible. They have a much higher duty of care to their clients because of the payment for services aspect of the relationship and that has nothing whatsoever to do with their basic motivations as "public spirited individuals".

In case of the "...nice sail..." that turns into a "...white squall...", yes that might happen, but a prudent skipper would have been prepared and have briefed the friends ahead of time, particularly if the friends were not experenced sailors. Likewise the hillwalkers should have been prepared for bad weather before starting and nothing says that they have to cross the stream that became a river. A prudent decision would be to wait for the water level to subside or take an alternate route. All of that changes if the skipper and the hill walk leader are accepting payment for their services and, especially, if they insist on carrying on.

True, people learn to adjust to risk by having their skill levels challenged but I wouldn't introduce novice sailors to the next level by taking them across the North Sea in my 30 foot sailboat if all they have sailed is an Optimist dinghy on a reservoir unless (a) they really wanted the experience and (b) they fully understood that they, with their limited experience, might have to take charge if I became incapacitated.

In the case of the paddleboard trip company it seems, from what I've read, that they did not properly assess the risks to their clients on that day and, as a result, didn't properly inform them of those risks. This meant that the clients weren't able to self-assess their skills against the likely conditions which meant that they didn't have the opportunity to say "I don't feel comfortable doing this". Thus the trip carried on when it should not have and people lost their lives.
 

Mark-1

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The MAIB report suggests the intent had always been to shoot the weir via the fish ramp (FWIABW). I'm staggered that shooting weirs is a normal of paddleboarding. Don't the skegs get wrecked and or the inflatables torn?
 

ylop

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I may not be an adrenaline junkie, but I believe that most worthwhile endeavours involve some degree of risk, and personal judgment regarding its magnitude. We all have to start somewhere,
Yes, and if I was relatively new to paddle boarding I would (and indeed have) paid a professional guide to lead us safely through the activity so that I could build up my own experience to help me make my own judgement.
and there will always be accidents and pioneers pushing the boundaries of what is possible and what is not.
The most basic stuff they got wrong was so far from pushing boundaries that it is impossible to comprehend why you’ve included that statement here. This wasn’t marketed as some pushing the boundaries trip, I’m sure none of them signed up believing they were in any more danger on this trip than on previous ones in benign water.
The group leaders in this incident appear to be public-spirited individuals dedicated to making life richer for others. I understand the immense pain and loss they have already endured, and I hope that the judge will impose only the lightest penalty.
Except in the most exceptional of circumstances the minimum sentencing guideline for gross negligence manslaughter is 1yr in prison - that would require a massive heap of mitigation and zero aggravating factors. A short sentence could be suspended. The top end (unless life is deemed appropriate to protect the public) - is 18yrs. I don’t think she’ll face anything close to that, but I’m sure she will have been warned to pack a bag and expect a significant sentence. Sentences should have a purpose, but it is a legitimate purpose to send a message to anyone else running cavalier operations to think again.
We would not want to live in a world where we felt the risk of taking our friend for a sail, walk, or paddle exceeded the joy written on their face they experienced upon completion.
Nobody is suggesting that these were the circumstances. If this was a group of friends who befell disaster and one happened to have defaulted to the group leader position and then found herself in the dock her legal advice may well have been quite different. Don’t conflate the too or imply that “we” all need to be worried. In fact even paid paddleboard guides don’t need to be worried if they are running responsible operations.
The trouble with any outdoor sport, is often the boundaries are unclear and constantly changing,
That may be true - but that’s exactly why you might engage professional guides! In this case the boundary might be ambiguous but I don’t think anyone looking at it objectively thinks they were just the wrong side of the boundary - they weren’t way out their depth and it should have been obvious to anyone with even basic paddleboard instructor training. Again if there was any hint of a grey area, presumably the defence would have found some expert witnesses who were prepared to stand in the witness box and say they would have gone out in those conditions with those client and that equipment.
what's fine one minute can become risky in the blink of an eye. Consider that nice sail with friends which quickly turns into a battle with a white squall. Or that easy hill walk route you've done a hundred times where the visibility dropped down to two meters, and the stream you were planning crossing was a river when you arrived. Every sport and pastime will have similar parallels.
I’ve been in all those situations - I wouldn’t consider doing them myself without some sort of vague contingency plan in my head and I absolutely would not take less experienced people without the capacity to mitigate those reasonably forseable scenarios.
Am not disputing that a bit more training, experience and flexibility of planning would have been appropriate in this circumstance.
I don’t think this is a “bit more training” - this was spectacularly stupid levels of preparation, in fact the organiser has admitted criminally poor preparation. The only way I can rationalise this having not been abandoned on the day is each instructor thinking “if it was as bad as it feels, surely my colleague would have said something”. That is not uncommon.
 

ylop

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More broadly, paddleboards are a lovely easy way to get on the water but I do worry that their accessibility for people who don't have much experience on the water makes them a danger. But I don't know what the stats are like for paddleboard accidents, maybe in reality they are fine - electric scooters look like death traps to me but apparently there's no clear evidence that they're more dangerous than bicycles.
There’s a LOT of people using paddleboards and relatively few getting into serious trouble, almost all the fatalities I’ve heard of have been in fast moving water (like rivers), and the mitigations are well known (and ignored in this case).

I’m quite sure if someone organised a “scooter tour” around London, didn’t take basic mitigations and led a group onto a motorway with tragic results that some people would blame the scooters but most would see that the organiser has to shoulder that responsibility.
 

billskip

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It's all been said and done before..... the stock result is usually "lessons will be learned "
But they are not.....
Remember the Lyme regis/ Lyme bay canoeing tragedy?
It's quite possible that these "instructor's" don't get taught the " lessons to be learned"

Who is responsible for qualifying the instructor and ensuring they are aware of history?
 

Marsali_1

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For anyone who wishes to review the full MAIB report it can be found here: Wayback Machine (you can scroll up to the start of the report from the page where it opens) and its annex document is here: https://assets.publishing.service.g...071e014ce8da/2022-13-Paddleboards-Annexes.pdf .

The facts are laid out (many of them will answer questions posed in this forum discussion) and the analysis is quite thorough. Re-reading the report, it is not surprising that the surviving instructor ended up in court and, had her partner instructor not drowned, he would have been in court with her.
 

NormanS

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I'm not sure that locking someone up in jail, at taxpayers' expense, solves any problems in this case. Yes, the person was careless, criminally careless if you like, but they now have to live out the rest of their life, knowing that their carelessness cost lives. That's quite a punishment.
 

steve yates

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The trouble with any outdoor sport, is often the boundaries are unclear and constantly changing, what's fine one minute can become risky in the blink of an eye. Consider that nice sail with friends which quickly turns into a battle with a white squall. Or that easy hill walk route you've done a hundred times where the visibility dropped down to two meters, and the stream you were planning crossing was a river when you arrived. Every sport and pastime will have similar parallels.

Am not disputing that a bit more training, experience and flexibility of planning would have been appropriate in this circumstance.
True but not applicable here. A river in full spate in danger of bursting its banks is an extremely dangerous beast indeed, even for skilled and experienced paddlers. It is never a place for beginners or the inexperienced to be, without exception.
This is not blame culture, there was nothing bordeline about it and it actually baffles me that an instructor would even consider taking a group down it. I can only assume they were used to paddleboarding on lakes or in the sea and but were not white water kayak instructors, so were actually ignorant of the immense power & dangers a river in full flood has. So made a tragic mistake. If they were also kayak instructors then a manslaughter charge is justified..
 

Marsali_1

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I'm not sure that locking someone up in jail, at taxpayers' expense, solves any problems in this case. Yes, the person was careless, criminally careless if you like, but they now have to live out the rest of their life, knowing that their carelessness cost lives. That's quite a punishment.
An often overlooked aspect of sentencing in cases such as this one is the deterence effect it should have on others who might be engaged in similar careless behaviour. You are right that time in prison likely wont change anything about the circumstances of this specific case or the, now criminally convicted, surviving instructor but that is not the sole intent of sentencing in any court case. Her sentence has yet to be delivered and there are many factors, including deterence of similar actions in others, for the judge to consider in determining a suitable penalty. It will be interesting to read the judge's rationale once it is delivered.
 

DreadShips

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I'm not sure that locking someone up in jail, at taxpayers' expense, solves any problems in this case. Yes, the person was careless, criminally careless if you like, but they now have to live out the rest of their life, knowing that their carelessness cost lives. That's quite a punishment.
An alternative - and angrier - view is that through stupidity or arrogance this person misrepresented their qualifications, abilities and experience for financial gain and ended up killing four people. A custodial sentence might encourage them to think carefully about all the choices that got them there and not just those that went wrong with this particular trip.
 

Mark-1

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I'm not sure that locking someone up in jail, at taxpayers' expense, solves any problems in this case. Yes, the person was careless, criminally careless if you like, but they now have to live out the rest of their life, knowing that their carelessness cost lives. That's quite a punishment.

I take your point, but three deaths is a lot to turn a blind eye to. On balance a prosecution seems a reasonable course of action.
 
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