Lessons to be learned by every leader, instructor, guide and coach from the independent investigation into the most recent accident involving multiple fatalities within adventure activities.

Personal observations from John Cousins

The accident: At about 09:00 on 30 October 2021, a group of nine stand up paddleboarders, two leaders and seven clients, on a commercial river tour from Haverfordwest to Burton Ferry, Wales, descended Haverfordwest Town Weir. Four of the group became trapped at the weir by the hydraulic towback and subsequently lost their lives.

The investigators: We are fortunate in this case that a publicly available investigation has been carried out. The tidal nature of the river below the weir meant that the Marine Accident Investigation Branch (MAIB) became involved. The MAIB investigates marine accidents involving UK vessels worldwide and all vessels in UK territorial waters. The sole objective of their investigation of an accident is "the prevention of future accidents through the ascertainment of its causes and circumstances". I can’t recall another adventure sport accident that has been investigated so rapidly and competently.

The report: MAIB have produced a very clear and concise report that clarifies many of the questions and misconceptions that surrounded this incident. I would urge everyone to read the report, which includes what happened, actions taken, and recommendations: MAIB investigation report 13-2022: Stand up paddleboards

The tragedy: This was a tragedy and as Chief Inspector of Marine Accidents, Andrew Moll OBE, said “this was a tragic and avoidable accident that had a profound effect on the participants and the families of those that lost their lives. Stand up paddleboarding is probably the fastest growing UK water sport, with participation in recent years growing by nearly 300%. However, like all water sports, those that buy or rent a paddleboard need to understand the risks”.

The relevance of this accident to climbing, walking and mountaineering: The last accident with multiple fatalities that I can recall within adventure sports was the Nanda Devi tragedy in 2019. In many ways there couldn’t be a greater contrast between that commercial exploratory Himalayan expedition and a river tour around Haverfodwest but there is much that can be learned from every case. Both trips were, at least, with adult groups and undoubtedly will not have the impact that the accidents to young people such as the Cairngorm tragedy or the Lyme Bay tragedy have had. Remember that the latter incident in 1993 led to the death of four teenagers on a sea kayaking trip in the Lyme Bay area on the south coast of England and resulted in the Adventure Activity Licensing regime for young people’s safety that remains in place to this day. Fortunately, such accidents are mercifully rare and therefore there is more reason to take the time to understand what happened here and learn all we can.

The lessons:

• Planning and preparation; “the leaders’ planning and preparation for the tour was inadequate and overlooked the extreme hazard posed by the weir”. In the aftermath of any incident your planning and preparation will always be in the spotlight (See sample forms, templates and documents in the members area of the MTA website)
• Equipment: “clothing, buoyancy aid and leash wearing by participants did not follow recognised guidance”. Familiarity with current good practice and consistency in what you issue to participants as well as checking the suitability of your own equipment, are all vitally important. (see back issues of the Professional Mountaineer Magazine and our latest handbooks for much good advice)
• Training, experience and qualification; “the leaders did not have the training, experience, or qualifications to lead the tour”. We do need to continue to strive to harmonise safety messages and training standards for the sport and the sector. The scope of each Mountain Training qualification is very carefully constructed and reviewed (as, no doubt, is each British Canoeing qualification for paddlesport activities). It is there to help individual leaders, instructors, coaches and deployers understand the bounds of where they are competent to operate. Every instructor, coach and leader needs to understand that going outside of the scope of the qualification for which they have been assessed and certificated puts them in a very vulnerable position. (see the introduction to each of our schemes for a defined scope)
• Public messaging and safety advice: “UK stand up paddleboarding safety messaging and training governance is inconsistent and there was no means for the participants to judge the proficiency of training and tour providers”. The Mountain training “qualification matrices” provides clear information on competence, relevant qualifications, experience and the process of ensuring you are qualified to do the job (see 'Who can lead, instruct or coach?' webpage). The immense challenge that the adventure activity sector has yet to resolve is how to give the general public (not the specialist public) clear, consistent safety advice. Having worked with many of the agencies involved in developing accreditation systems over the last thirty years I believe it will require government support and direction if we are ever to help the type of people that set out on that fateful day in Haverfordwest. The public should be able to recognise businesses that are competent to deliver training, tours and expeditions with an accreditation scheme that encompasses the complete suite of current and emerging activities (see Adventuremark for non-statutory accreditation and AALA, Adventure Activities Licensing Authority, for young person’s safety)

John Cousins - 23rd December, 2022