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The Marine Casualty Investigation Board (MCIB) has recommended that the Minister for Transport should consider introducing regulations specific to the installation and operation of articulated hydraulic deck cranes on fishing vessels.

The MCIB recommendation is one of a number issued in its report inquiring into a crush injury sustained by a crewman on board a fishing vessel off the Cork coast in November 2021.

Recommendations in relation to risk assessments, safety legislation, hazard warnings and training for use of articulated deck cranes are also published in the report.

The incident occurred on board the 21 metre-long fishing vessel Aquila which was fishing south of the Kinsale gas rigs on November 7th, 2021.

The vessel with five crew onboard had left the fishing port of Union Hall, Co Cork, the night before. Wind at the time was force three, westerly, with a moderate sea.

The wooden twin trawler was rigged for Danish seine net fishing

As the report states, “at approximately 12.00 hrs on the 7th November, the fishing vessel was at the fishing grounds and the crew were hauling the second haul of the day using the vessel’s net handling crane”.

It says that the crane’s hydraulic system “experienced a sudden loss of hydraulic oil pressure, causing the crane’s jib and power head to uncontrollably lower inboard trapping a crew member between the power head and the underside of the deck supporting the net drum”.

The crewman, who is from the Philippines and had been on the crew for two years, suffered crush injuries.

The vessel’s skipper contacted the Cork Coast Guard Radio (CGR) by VHF radio at 12.38 hrs, advising it of the incident and requesting a medical evacuation of the injured crewman.

It says that at approximately 15.00 hrs, the Irish Coast Guard helicopter R115 from Shannon airlifted the injured man ashore to Cork University Hospital (CUH) for medical attention.

The man was discharged from CUH on November 8th, and was passed fit to fly home. He returned to the Philippines to recover.

It says he recuperated, and has since returned to work as a fisher onboard an Irish registered fishing vessel.

More details are in the MCIB report here

Published in MCIB

The Marine Casualty Investigation Board (MCIB) has said that boarding and disembarking risk assessment and associated policies and procedures should “immediately be reviewed” after the serious injury of a diver working on salmon farms off the Galway coast.

The 33-year-old male contract diver, who was contracted by the salmon farm operators to inspect and maintain the salmon cages around Kilkieran Bay, Co Galway, sustained his injuries when he was pinned between two vessels during a transfer from one to the other off Ardmore pier on November 8th, 2022.

The incident occurred when a feed barge was making a rendezvous with a smaller vessel carrying five people, including two contract divers.

The injured casualty was brought back onboard the vessel and was subsequently airlifted to Galway University Hospital (GUH) where his injuries were assessed and included multiple fractures to the pelvis and fractured hip socket joints, the MCIB report says.

At the time of the interview with the MCIB in January 2023, the casualty was out of work, the report notes, and was walking aided by crutches.

Visibility was moderate or poor and winds on the day in question, November 8th 2022, were generally fresh force 5 to strong force 6 (mean wind speed 17 to 27 knots) and gusting up to 40 knots for a time.

In its analysis, the MCIB says that “means of safe access was not appropriate for transferring from one vessel to another and the practice of stepping over the side rails and onto the feed barge’s tyre fender became normalised”.

“ The prevailing conditions including the direction and height of the swell were contributing factors to this incident,”it says, as the licence required the vessel to operate in favourable weather.

There were missed opportunities during the purchase process to verify safe access to and from the vessels as both had safe means of access, but were not compatible when the vessels were moored alongside each other, the MCIB report says.

It says the operator's risk assessment failed to identify the deficiencies in vessel transfer operations and in particular with regard to third parties such as the contracted diver.

It says while the operation was identified by the operator under their safe systems of work, it was not authorised by the Marine Survey Office by way of a “permit to tender”.

In a series of recommendations to the salmon farm operator and owners of the two vessels on reviewing procedures, the MCIB also called on the Minister for Transport, in conjunction with his marine counterpart, to consider if it is “ appropriate or not” to issue a Marine Notice or similar, directed to the operators and those involved in marine aquaculture activities.

It recommends that the Marine Notice would remind operators and all involved of the dangers associated with boarding and transiting vessels at sea;

that operators have a safe system of work including suitable and sufficient risk assessments in place for operations carried out at sea including transfer of personnel onto fish cages and feed barges;

and that operators take steps to ensure that vessels transferring personnel at sea are properly licensed in accordance with passenger boat legislation and “permit to tender” for tendering operations as applicable.

The report is here

Published in MCIB

The Marine Casualty Investigation Board has recommended that the Minister for Justice should consider carrying out an audit of the crewing arrangements of any fishing vessel or vessels to ensure non-EEA crew are compliant with the rules governing work permits.

It also says the minister should also ensure there is a robust system in place to ensure those given permits have a sufficient knowledge of English to be able to communicate with fellow crew on board Irish registered fishing vessels.

The MCIB recommendations have been made on foot of its investigation into the circumstances surrounding a serious leg injury sustained by a crew member on board a vessel, the John B, off the east coast in July 2020.

The incident occurred when the crew’s leg became trapped between the centre weight and the weight retaining cage at the stern of the vessel during a prawn fishing operation on July 17th, 2020.

The load was adjusted allowing the injured crew member to extricate his trapped leg from the grip of the centre weight, and other crew provided first aid.

The owners were informed, the vessel steamed to the nearest port, Howth, and the man was taken to Beaumont Hospital emergency department by private vehicle.

No external medical or emergency assistance was sought or requested by the skipper or the owners, the report notes.

The report concludes that no risk assessment for hauling the nets was shared with the crew, and some were employed without mandatory training.

It says the skipper was “inexperienced on the vessel and relied on his crew to recover the gear unsupervised, while he remained in the wheelhouse”.

It says evidence from the skipper asserting that the crew member had been warned about the dangers of standing on the weight while recovering the fishing gear, but continued to do so, “is not supported by any detail or any other evidence”.

It also says this assertion is denied by the casualty.

It says the design and layout of the fishing gear on this vessel was poor, making communication between the winch operator and deck crew difficult.

It says the winch operator could not see the crewmembers feeding the nets on to the reels, and clear lines of communication were also not in place, given that the winch operator could not see the crewmembers feeding the nets on to the reels.

“ Had there been a safe design and planned effective communications in place effective supervision could have been adhered to,”it says.

“ Communications in general onboard the vessel was hampered by a language barrier between crewmembers,” it says and there was a dispute over the number of crew on board during the trip.

The MCIB says it “appears to be the more probable case on the basis of the evidence available” that the crew comprised five and the skipper on the trip in question, and not the normal crew of six and the skipper.

“One man less in the crew complement can of course increase the fatigue factor and also increase the workload on the remaining crew,” the report says

“In addition, there is the issues as to appropriate manning for particular operations. The Working Time Regulation records provided raise some issues as to how many of the crew were working on the operation of deploying and recovering the nets on the day in question,”it says.

“Given the experience of the crew, the nature of the operations and the nature of the trip, a crew of six and a skipper would have been more appropriate on the vessel,” it says.

Once the incident occurred, given the seriousness of the injury, the skipper should have contacted Medico Cork through the Coast Guard Radio Station for advice and arranged safe evacuation to the hospital, but this did not occur, it says.

“ The owners and operators of the vessel did not comply with a variety of legislation in place governing operations and safety of the crew of an Irish registered fishing vessel,”it says.

“It has not been possible to determine definitively who was the employer of the casualty or the other crew members at the time, given the lack of documentation,”it says, and there is an issue with determining the owner.

“ It is essential on any fishing vessel to have clarity on ownership and on the employer given that the regulatory regime imposes duties on owners and on employers,”the MCIB says.

The vessel was submitted for decommissioning, and the report makes a number of recommendations addressed to the registered owners, to the Minister for Justice, Minister for Transport and Bord Iascaigh Mhara.

The full report and recommendations are on the MCIB website

Published in MCIB

Following a recent MCIB report into a serious deck accident aboard a fishing vessel in Dingle Bay last year, the Department of Transport has published a Marine Notice reminding mariners of the dangers of fishing alone.

The MCIB report explains how a lone fisherman on the 9.9-metre An Portán Óir was shooting lobster pots on Friday 14 October 2022 when his leg became entangled in the pot ropes and he remained trapped until he was rescued around four hours later.

It was established that the lack of a personal locator beacon (PLB) was a contributing factor, and that the fisher’s severe pain experienced in the incident could have been alleviated if he had access to a knife.

In response to the report’s recommendations, the Marine Notice reminds owners and operators of fishing vessels of the dangers associated with fishing alone and of the importance of always wearing an approved personal flotation device/lifejacket and a personal location beacon while on deck. Personal locator beacons should be registered.

In addition, lone fishers are recommended to have a suitably protected knife on their person while on deck during fishing operations, especially during potting operations. Knives may also be secured at strategic locations on deck to be available quickly in case of entanglement.

Lone fishers are recommended to carry out a personal risk assessment before each voyage, to remind themselves of the potential risks and to take mitigation measures as required.

More information can be found in Marine Notice No 71 of 2023, attached below.

Published in Fishing
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A recent Marine Notice from the Department of Transport draws attention to the recent report by the Marine Casualty Investigation Board (MCIB) on an incident involving a fishing vessel in Dingle last year.

As previously reported on, it was found that an incorrectly designed electrical system on the French-registered FV Bikain was the main cause of a serious collision with a pontoon in Dingle Harbour which caused extensive damage on 25 November 2022.

It was established that the design of the electrical system necessitated that emergency batteries were required to be in use at all times for the operation of the vessel, but emergency batteries should only be used for emergency situations when the main power supply fails.

The MCIB has made the following recommendations to owners:

  • A list of critical systems should be carried onboard vessels with a maintenance and testing schedule included for each critical system or piece of equipment.
  • Records of test and maintenance should be retained onboard.
  • Sufficient spares should be carried onboard to enable repair of a vessel’s critical systems in the event of failure.
  • Any failure of critical systems should be reported immediately, and a thorough investigation carried out to identify the root cause.
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There are two very specific points in the annual report of the Marine Casualty Investigation Board for last year (2022), which, in pursuance of maritime safety, should be heeded by the sectors involved – watersports and the fishing industry.

The Chairperson of the Board, Claire Callanan, recalls the recommendations made in the 2021 report about incidents associated with water sports and water recreational activities and says: “The MCIB urges those bodies to whom recommendations have been addressed in these recent reports to take steps to improve much-needed safety regimes..”

On the fishing industry, she says: “It is clear that many incidents on fishing vessels are not reported to the MCIB as required by legislation.”

 Marine Casualty Investigation Board Chairperson Claire Callanan Marine Casualty Investigation Board Chairperson Claire Callanan

These are strong comments on the sectors concerned.

“In the MCIB Annual Reports for 2020 and for 2021 we reported on incidents associated with water sports and water recreational activities. We focussed on the recommendations for organisations (especially clubs and commercial entities) aimed at improving their safety standards. In February 2023 we published a report following a lengthy investigation into a tragic fatality that focussed on the safety regime in kayaking in third-level institutions.”

The Chairperson says that the MCIB has made extensive recommendations to the Minister, to Water Safety Ireland and to Canoeing Ireland and Sport Ireland, including:

  • That Canoeing Ireland, in conjunction with Sport Ireland, should consider the establishment, and promotion of a register of Canoeing Ireland qualified instructors with their qualifications that would be available to the public.
    • That Canoeing Ireland, in conjunction with Sport Ireland, should consider the establishment of a scheme for the audit of the safety policies and practices of entities affiliated with this national governing body.
    • That Water Safety Ireland should consider actions to further promote both public awareness of kayaking safety and measures to prevent kayaking accidents

On the fishing industry, Ms.Callanan comments: “ It is clear that many incidents on fishing vessels are not reported to the MCIB as required by legislation. Even from the limited information available to the MCIB from Coast Guard situation reports it appears that many incidents could have been avoided by safety assessment and planning and by proper training of crew.

As noted in MCIB Report No. 302/2022, the Maritime Safety Strategy identified that the fishing vessel sector accounts for a significant proportion of all maritime fatalities and that fishing vessels less than 15 metres (m) in length make up 90% of the Irish fishing fleet in numbers. Fishing vessel safety, particularly in relation to small and medium fishing vessels, is a particular concern. Among the key factors contributing to the loss of life in the fishing sector is working alone and fatigue.”

The full MCIB report for 2022 is available on the MCIB website

Published in MCIB

An incorrectly designed electrical system on a French-registered fishing vessel has been identified as the main cause of a serious collision with a pontoon in Dingle Harbour which caused extensive damage last November.

The Marine Casualty Investigation Board (MCIB) has recommended that the French authorities should test and verify the automatic operation of emergency electrical systems during surveys of fishing vessels following its inquiry into the incident.

The incident occurred on November 25th, 2022 in Dingle Harbour, Co Kerry when the French-registered fishing vessel named Bikain was preparing to go to sea to resume fishing.

FV Bikain Alongside in DingleFV Bikain Alongside in Dingle Photo: MCIB

The marine casualty caused “serious damages to the pontoons and the support piles and serious damages to boats moored on the pontoons at the time”, the MCIB says. There were no injuries reported.

The vessel was crewed by a Spanish skipper and Spanish crew, and the skipper had extensive experience and had been sailing on fishing vessels since he went to sea around 41 years ago, it says.

“serious damages to the pontoons and the support piles and serious damages to boats moored on the pontoons at the time”

Senior crew also had Spanish certificates endorsed for sailing on French-flagged vessels and were all suitably experienced for this type of vessel, it says.

The vessel had been fishing off the west coast of Ireland and had come into Dingle Fishery harbour centre on 23rd November 2022, due to forecasted bad weather, it says.

As it prepared to leave two days later, the main engine was started, and checks for sailing were being carried out when the controllable pitch propellers (CPP) went to the full astern position.

“ The Skipper tried to stop the main engine with the emergency stop button on the wheelhouse console, but this failed,” the MCIB says.

“ The mooring ropes holding the vessel parted, and the vessel went quickly astern and made heavy contact with the southern boat marina pontoon causing extensive damage to the pontoon and to several boats that were secured there at the time,” it says.

“ The main engine was eventually stopped by shutting off the fuel, and the vessel drifted across the harbour basin,” it says.

“The FV Danny Finn cast off from the western side of the pier and rushed to assist by going alongside the FV Bikain and connecting ropes to assist the vessel and tow her back to the main quay wall where she was then tied up safely,” it says.

The Dingle harbour master activated the port emergency response plan to secure the drifting and damaged boats and pontoon sections.

Divers were mobilised, as well as boats, to tow the damaged boats and secure them to safer moorings. A clean-up operation was also carried out to collect debris from damaged boats, and some were lifted out to the slipway, the report says.

“There were no injuries and no pollution, but extensive damage was caused to the southern pontoon and moored boats,” it says.

“ As this was a French-flagged vessel, the Director of the Bureau d’enquêtes sur les événements de mer (BEAmer) (French Marine Casualties Investigation Office of the Ministry of the Sea) also decided to investigate jointly,” it says.

The report, which makes a number of recommendations, concludes that the electrical system was incorrectly designed on this vessel, and this was the root cause of the casualty.

“ The design of this system necessitated that the emergency batteries were required to be in use at all times for the operation of the vessel, but the emergency batteries should only be used for emergency situations when the main power supply fails,” it says.

“Previous failure of the charging system was not identified as a critical failure and should have instigated a full investigation to identify why these failures were occurring. This investigation should have identified the design faults and prevented this casualty event,” it says.

The MCIB also notes that there were no written procedures for the test and maintenance of “this critical system onboard the vessel”.

The full report is here

Published in MCIB
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A skipper survived severe pain during a deck accident which could have been alleviated if he had been able to access a knife to free his leg, according to the official investigation.

The Marine Casualty Investigation Board (MCIB) report into the incident on board An Portán Óir, a 9.9-metre fishing vessel, in Dingle Bay, Co Kerry, last October noted that lack of a personal locator beacon (PLB) was also a contributory factor.

However, having a designated person ashore to raise the alarm if the vessel was overdue proved “invaluable”, the MCIB report notes.

The report recounts how on Friday, October 14th, 2022, the boat was taken on a routine fishing trip to lift, bait and shoot lobster pots in Dingle Bay.

“The boat was operated by the owner (the Skipper), and he was a qualified and experienced boat operator with valid certification,” it says.

The Cygnus 33 GRP decked vessel with an inboard diesel engine is registered in Tralee, Co Kerry.

“The skipper was shooting the final string of 30 lobster pots, with ten pots in the water, when his leg became entangled in the pot ropes. The boat was in gear to stretch the string, and the rope tightened around the skipper’s leg, and he was pulled aft,” it says.

“ The skipper grabbed the rope between the pots, and tied it to the handrail to avoid being pulled overboard. He was unable to free himself as the rope around his leg was under tension, and he remained stuck in this position until he was rescued around four hours later,”it says.

It notes that the skipper normally had a knife tied to the rails aft, but this had been removed during painting and had not been replaced.

This was “a major factor in the skipper being unable to free himself”,it says.

It also notes that he was not wearing an approved personal flotation device/lifejacket and PLB on deck and if he had he would have been able to activate the PLB and get assistance as soon as the incident occurred.

Under Section 9.2.4 of the Code of Practice for the Design, Construction, Equipment and Operation of Small Fishing Vessels of less than 15 metres length, “an approved PLB capable of transmitting a distress alert on 406 MHz band, shall be provided for each person on board and shall be carried by each person on deck at all times”.

“Each PLB should be ready to be manually activated”, the code states.

“ This lack of PLB is considered a contributing factor in the extent of the injuries sustained,” it says.

The alarm was raised when the boat failed to return, and a search was initiated with the Dingle lifeboat, local vessels and Coast Guard rescue helicopters.

The skipper was treated in hospital for “severe” muscle and nerve injuries which prevented him from returning to work for some time.

“The skipper always had a designated person ashore who was aware of his voyage and his expected return time. This proved to be invaluable,” the report says.

“When the alarm was raised, and the rescue services were tasked, there was also an excellent response from the local community, and even though the skipper suffered serious injuries, without the rapid response, the outcome may have been far more serious,” it says.

Read the full report here

Published in MCIB

Minister for Transport Eamon Ryan has today (Thursday 25 May) announced the appointments of John Carlton, Deirdre Lane and Captain Phil Murphy as board members of the Marine Casualty Investigation Board (MCIB).

The appointees are additions to the board and provide a replacement to Frank Cronin, who ended his second term with the board on 31 March 2023.

John Carlton is the port services manager at Shannon Foynes Port Company. He is responsible for managing all port services, port operations, marine operations, engineering and asset management, project management and the environmental health and safety (EHS) function of the company. He is a qualified marine engineer and has a broad range of marine engineering, general engineering, port operations, EHS management and senior executive management/corporate governance experience.

Deirdre Lane is the Harbour Master for Dunmore East. She is responsible for the safe and efficient operation of the harbour, including the day-to-day management and maintenance of the harbour and its installations. She is a Master Mariner and holds a first class honours degree in Nautical Science and an MSc in Shipping Operations with a specialist strand in Safety Management. She has also completed training in internal auditing and marine incident investigation and analysis.

Phil Murphy is the senior marine officer at Wexford County Council. He is responsible for oversight and management responsibilities of all the piers, harbours and marinas in the County, including New Ross Port. He is a Master Mariner and also holds a diploma in Nautical Studies and Port Management.

The three appointments were made pursuant to a Public Appointments Service process.

Commenting on the appointments and Frank Cronin’s departure, Minister Ryan said: “The appointees bring a wealth of knowledge and experience in several areas that are important to the continued operation of the Marine Casualty Investigation Board.

“I want to thank them for giving their time and expertise to the important work the board undertakes. I also wish to thank Frank for his dedication and commitment to the MCIB since his appointment in 2017. I wish him the best of luck in his future endeavours.”

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The Marine Casualty Investigation Board (MCIB) has criticised the “general safety environment around paddlesports in Ireland” which it has identified as a “systemic factor” in a serious incident involving kayakers in Donegal’s Mulroy Bay last year.

A group of six kayakers were rescued in the tidal sea lough on March 19th, 2022, but the MCIB has classified the event as one that “posed a threat of death or serious injury”.

It has identified a combination of “causal and contributory factors”, including unsuitable weather conditions; inadequate training and qualifications; inadequate trip and contingency planning; inadequate safety equipment; inadequate protective clothing; and an inadequate safety environment.

This incident occurred during a commercial, guided trip, involving a trip organiser and five clients, which was intended to be about three kilometres and involved crossing the sea lough.

The clients were adults who typically had little or no kayaking experience. Only one client wore a wetsuit as thermal protection against the effects of cold water immersion, while the others wore clothing such as jeans and winter coats, the report says.

It says the group got into difficulty when the wind speed increased and the sea state deteriorated. The double kayak capsized but its two clients were able to right the kayak and make their way to one side of the lough.

Another two clients, in single kayaks, separately made their own way to the other side of the lough, after one of them capsized and swam for about 20 minutes to reach the shore.

The remaining client and the organiser both capsized and lost contact with their kayaks. They drifted in the water for approximately one hour, isolated about mid-way across the lough, until they were rescued by the Irish Coast Guard.

The report says they required hospital treatment before being released later that day.

“This rescue only became possible because of the diligent actions of a member of the public, who saw people in the water and notified the emergency service,”it says.

The report says the trip organiser’s training was primarily in seamanship skills for the crew of a ship, which he undertook about seven years ago, followed then by about one year working offshore as a crewmember on a commercial fishing boat.

It says he had attended a three day first aid course about nine months before this incident. He had the Level 2 Kayak Skills Award from Canoeing Ireland (CI), which he had received about nine months before this incident.

It quotes the organiser’s website, which stated that “we are an experienced team and we are all certified kayaking instructors that will take you on an amazing kayaking trip in any of the locations we operate in”.

“However, the MCIB’s investigation identified how the trip organiser is not the holder of a kayaking instructor qualification from either CI or any other national governing body,”the report says.

It also says the organiser had no formal training in the planning or navigation of kayaking trips, such as the Essential Coastal Navigation award from CI, and no formal training in the methods of rescuing kayaks or capsized kayakers, or the management of kayaking incidents.

A participant who booked the trip told the organiser that they had all kayaked before and that they could all swim.

The report says that “when the trip commenced he found out that most of them had little or no kayaking experience, and that one of them could not swim”.

It said the organiser did not operate a process of a written questionnaire or forms to be completed by participants in advance of a booking, such as those describing their swimming ability, kayaking experience or details of health or medical conditions.

On the day of the trip, a small craft warning was in effect for all Irish coastal areas, meaning that winds of at least force 6 were expected.

All of the group were provided with correct personal flotation devices, it says.

It says the trip organiser had a mobile phone placed within the pocket of his raincoat, which became inoperable when exposed to water after he capsized and entered the water.

He had a first aid kit stowed in his kayak but did not have a phone in a waterproof pouch, and did not have recommended safety equipment, as outlined in the Code of Practice for the Safe Operation of Recreational Craft, such as a VHF radio; Personal Locator Beacon (PLB); signalling flares; spray deck; tow rope; or emergency shelter.

The report says the alarm was raised by a member of the public who has lived in the area for many years and had kayaked on this sea lough many times before.

“She had considered going out kayaking on the day of this incident but had dismissed this idea because it was too windy. Her experience is that the lough is generally safe for kayaking, but it has a noticeable tide, and the weather needs to be calm for kayaking to take place safely,”it states.

The MCIB report makes a number of recommendations, and notes that it has investigated a number of kayaking and canoeing incidents at sea and on inland waters since 2007, as a result of which eight fatalities occurred.

It lists the kayaking/canoeing incidents are as follows:

  1. MCIB 155 – Gaddagh River, 2007.
  2. MCIB 180 – Clodagh River, 2010.
  3. MCIB 241 – Inchavore River, 2014.
  4. MCIB 275 – River Suir, 2017.
  5. MCIB 283 – Roughty River, 2018.
  6. MCIB 285 – Lough Gill, 2019.
  7. MCIB 296 – Caragh River, 2019.

It says that the circumstances of the above kayaking incidents have some common features in that incidents occurred in winter or spring months, which has implications for cold water shock and the onset of hypothermia.

It also found common features such as:

  • skills levels of the kayaker/instructor not being sufficient for the type of water conditions;
  • mixed ability groups do not have sufficiently qualified leaders/instructors;
  • incidents occurred during the latter half of the excursion.

The MCIB says its annual reports for 2020 and 2021 strongly encouraged all organisations (especially clubs and commercial entities) associated with water sports and water recreational activities to audit their safety systems, and to have regard to the Code of Practice for the Safe Operation of Recreational Craft and all guidelines or recommendations issued by any governing sports bodies.

It says it made recommendations in 2021, including :

  • The establishment of a directory of commercial providers of coastal sea and river paddle facilities;
  • How best to enhance safety sHow best to enhance safety standards within the commercial paddlesports provider sector;
  • A mandatory registration or licensing scheme of instructors and their qualifications.

The report says it is” disappointing to note that the MCIB continues to be advised of situations where little or no regard was paid to governing body safety guidelines”.

“The MCIB has observed a continuing increase in the number of very serious incidents involving paddlesports, some of which could very easily have led to fatalities,” it says.

The full MCIB report is here

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