The four paddleboarders who died in the tragedy at Haverfordwest Town Wier ‘lost their lives because the leaders of the tour were unaware of the treacherous conditions at the weir’ said an official report released this week.
Participants in the Salty Dog Co Ltd tour had not been given a safety briefing prior to departure and had not been told of the presence of the weir or how to descend it, said the report.
No written risk assessment had been carried out prior to departure.
Morgan Rogers, Nicola Wheatley, Andrea Powell and Paul O’Dwyer tragically lost their lives at the weir during a paddleboarding tour on October 30 last year.
A report issued this week by the Marine Accident Investigation Branch (MAIB) pointed out that there were also problems with signage and responsibility for the weir.
The report was written for the prevention of further accidents and not to create an assumption of blame or liability.
The report stated that the group’s two leaders, one of which was Mr O’Dwyer, had visited Haverfordwest in August for a trial run of the Pembrokeshire Tour.
The pair were qualified to teach stand up paddleboarding to beginners and novices in benign conditions but not to lead tours on fast-flowing rivers.
When they visited the river in the summer, conditions were benign.
However, on the day of the October trip they had not checked conditions at the weir. Assessments after the tragedy said that on that day the weir hazard level was ‘very high’ and the likelihood of the weir to cause harm ‘very likely’.
The leaders were also unaware of the high river level, tidal conditions and flood alert in force at the time.
The MAIB report stated that the participants were not briefed on the presence of the weir or how to descend it before setting off on the stretch of the Cleddau near to Haverfordwest’s Morrisons store.
It said the participants were unaware that they would be descending the weir and did not know that, if they were uncomfortable doing so, they could exit on the left-hand side of the river and walk around it.
Near to the group’s launch point was a sign that warned users that the weir was dangerous, advised them to portage it, meaning to exit the river and carry their craft around the weir.
The investigation found that the group’s leaders did not heed that sign.
However, it also concluded that the sign, and others on the river, did not follow the British or international standards for national water safety signs; the one by the weir was faded and the one close to the entry point was closely scripted and used technical language.
The report stated that only five of the paddleboarders were wearing buoyancy aids, none of them had a quick release waist leash and only five were wearing wet or dry suits.
“The leaders should have insisted that buoyancy aids were worn by both themselves and the participants,” said the report, which added that in these conditions, where there was a danger of being caught on something, a quick release waist leash was advised.
It said that the fact that the participants had ankle leashes may have ‘adversely affected their chance of survival’.
The competency of the tour members who had not been previous customers had not been assessed prior to setting off.
The participants were not required to complete a legal disclaimer, medical declarations, or provide emergency contact details before starting the tour.
Crucially there was no written risk assessments for the Pembrokeshire Tour and online risk assessments from Haverfordwest Kayaking Club (HKC), which warned that, at high water levels the town weir becomes extremely dangerous with high potential for loss of life, had not been accessed.
“Had the Salty Dog Co Ltd produced a methodical, documented risk assessment for the tour, searching for advice on the passage down the Western Cleddau from local sources such as HKC, the organisers would have understood the hazard of the weir, adapted their plan, not launched onto the river Cleddau, and thereby have avoided placing the tour participants in danger,” said the report.
“Regrettably, the owner decided to commence the SUP tour without an accurate understanding of the risk to its participants.”
The report stated that the group leaders seemed confident and competent, despite the fact that they were not qualified to lead tours or expeditions.
This meant that the participants did not challenge or question them but trusted them to safely guide them to Burton Ferry.
The MAIB noted that, because there is no active national governing body for the sport of stand up paddleboarding in the UK, there is no consistent safety messaging in respect of potential risks from weirs and other hazards, or on the wearing of appropriate safety equipment.
There is also no framework to judge the competence of those businesses offering stand up paddleboard training, tours or expeditions.
The report outlined how on that tragic morning the tour leader instructed those close by to follow her and keep to the centre of the river as they approached the weir.
Kneeling on her SUP, she slid down the fish pass in the centre of the weir and was swept quickly downriver.
The next participant was unable to align her SUP with the fish pass and was washed over its right-hand side. She fell from her SUP into the river and was swept downstream.
As the other participants approached the weir, the fellow leader, who was following at the rear, told those nearby to kneel down and keep left.
Within about a minute, the next six participants of the group descended the weir. As they did so, their boards pitched forward and all six of them fell into the turbulent water at the foot of the weir.
Three of the group were washed clear and swept downstream, holding on to their SUPs.
The other three were trapped within the recirculating flow on the downstream side of the weir; two to the right of the fish pass and one to the left.
The other leader saw that some of the party were in difficulty and left the river. He jumped back in above the weir but in trying to save the others lost his own life.
“It is almost certain that those who lost their lives were unable to escape these forces [of hydraulic towback] until, exhausted, they were immersed and drowned,” said the report.
The report said that there was no record of any risk assessment for the Haverfordwest Town Weir or evidence that appropriate control measures, such as those proposed in the Canal and River Trust guidance, had been put in place.
In fact, at the time none of the local agencies or authorities considered that they were responsible for the weir and because of that the hazards it posed to river users were ‘inadequately mitigated’ and the signage of the hazard was ineffective and did not conform to national guidelines.
READ MORE:
- Safety issues identified in Haverfordwest paddleboarding tragedy
- Investigations continue into Cleddau paddle boarding tragedy
More than six months after the tragedy it was finally agreed that Dwr Cymru Welsh Water owned the weir, with the land on either side of it lying under PCC’s jurisdiction. Milford Haven Port Authority (MHPA) managed navigation on the tidal water up to the southern face of the weir.
On August 2 this year, representatives from Dwr Cymru Welsh Water visited Haverfordwest Town Weir with other stakeholders and commenced a risk assessment.
The closed-ended nature of the weir without steps or a ladder meant it was impossible for the four kayakers to escape from the water, access for potential rescuers was also challenging.
The report said that in 2003 the fish pass part of the weir had been replaced. Canoe England had been consulted and had recommended insertion of corner fillets to create flush points that would wash anyone trapped in the weir downstream and considerably lessen the hazard of potential drowning.
The corner fillets were inserted but the effectiveness of the fillets to create ‘washout’ zones had not been assessed and, after the tragedy, no flush points were observable at the weir in similar conditions.
READ MORE:
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- Haverfordwest paddleboard incident: Fourth person dies
The report noted that the Health and Safety executive prohibited Salty Dog Co Limited from conducting instructing, coaching or leading stand up paddleboarding, whether of individuals or groups, in Great Britain.
“This was a tragic and avoidable accident that had a profound effect on the participants and the families of those that lost their lives,” said Andrew Moll, OBE, chief inspector of marine accidents.
"Stand up paddleboarding is probably the fastest growing UK water sport, with participation in recent years growing by nearly 300 percent. However, like all water sports, those that buy or rent a paddleboard need to understand the risks.”
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