An investigation into an incident where a party of 15 kayakers encountered difficulties during a round trip from Bulloch harbour to Dalkey island on Dublin Bay last September has found that “disregard for Met Éireann forecasts” contributed to a decision to embark on a “potentially unsafe tour”.
All kayakers returned or were rescued in the incident which occurred on the evening of September 13th, 2020, but one of the kayakers was in the water for 40 minutes and unable to return independently.
The Marine Casualty Investigation Board (MCIB) report published yesterday (October 28th) notes that while a small craft warning was not in place earlier that evening, it was in place by the time the group was setting out to sea.
The MCIB says that an” apparent complete disregard” for the instructor training regime run by Canoeing Ireland (CI), the national governing body for kayaking, “seems to have contributed to the decision to embark on a potentially unsafe tour”.
A photo of two canoes ashore at Bulloch Harbour from the MCIB report
The party of 15 kayakers involved three instructors and 12 participants on a guided kayak coastal trip from Bulloch Harbour to Dalkey Island and back of approximately 2.86 nautical miles.
Both kayaks with cockpits and “sit-on-top” kayaks were used, the report says.
After leaving Bulloch harbour, the kayakers became separated into two groups with a “small group drifting northwards” and a “large group” making its way “(eventually) to the north end of Loreto Convent”.
Three “999” calls alerted the rescue services to the incident, recording "concern on the part of members of the public that the kayakers were struggling”.
The calls said that “some had become separated from the main group and were drifting towards Dublin harbour; that one seemed to have capsized; that a kayaker appeared to be in the water; that the instructors were rushing to assist; that the “small boat” (presumably a reference to the Royal National Lifeboat Institution inshore lifeboat should be sent to assist; and that the kayakers were in trouble”.
One of the kayakers capsized three times. An Irish Coast Guard ((ICG) rescue helicopter, RNLI all weather (ALB) and inshore (ILB) lifeboats and a land-based Irish Coast Guard crew responded, as did the tour organiser who paddled out to bring a group of nine kayakers ashore at Loreto College. However, in emails to the MCIB investigator, the organiser says her concern for the group's safety was "nothing to do with my tour or the conditions".
"It was caused in its entirety by the disruption to their equilibrium with the sudden and unnecessary arrival in our space of the ICG search and rescue helicopter, the RNLI ALB and the ILB lifeboats and the ICG land-based vehicle," she states.
"The approaching tsunami of rescue services swarming around my guests suggested an urgent and imminent danger where none existed," she stated by email.
The investigation was unable to determine the precise level of skills of all instructors, and notes that at least two of the participants did not have sufficient experience for the conditions.
It says “the qualifications ascribed by the organiser’s observations to one or other of the instructors (kayaking level 3 sea skills, kayaking level 4 training and kayaking level 2 instructor) “did not meet the appropriate qualifications recommended by CI for an instructor taking out a group in conditions similar to those which were encountered on the tour”.
The weather report was noted moderate to fresh winds of Beaufort force 4 or 5.
It says the organiser’s observations did not refer to the Code of Practice for safe operation of recreational craft, and the report says “it is reasonable to assume that no regard was had to its contents” and that this contributed to the decision to embark on a “potentially unsafe tour”.
A fisherman who assisted one of the two groups of kayakers recalled that local conditions were such that the combination of an ebb tide with wind from the south/south west had the effect of wind against tide giving rise to “white horses” and a sea swell of approximately 1.5 metre, the report says.
“While this contradicts the data evident from the tidal streams... challenging sea conditions were encountered,” it says.
It says the overall ratio of participants to instructors was in keeping with that identified by CI’s website, namely a ratio of 1:4.
The report says two of the participants indicated that no warnings were given to them that they would become immersed in the water, and that “they were not told what to do in the event of their becoming immersed in the water”.
It says the fisherman “noted that the female kayakers whom he took on board were tired, cold, wet and fatigued and would not have made it ashore on their own”.
The report says that one of these was “in an uncontrolled situation in and out of the water for a period of approximately 40 minutes”.
This participant told the report of feeling “in deep water” shortly after leaving the calm of Bulloch harbour “in the sense that she believed she had no control over the direction of her kayak and that the waves were taking her where they wanted”.
She “recalled being terrified, not being able to speak and having to try to attract the attention of the instructors by waving her hands”.
A big wave flipped her over and her personal flotation device “burst open”, but still remained on her upper body.
She was separated from her kayak for a time, swallowed sea water when swimming back to it, and was “coughing and expending energy” in a bid to keep her head above water, before being assisted.
Two instructors were unsuccessful in addressing the situation, it says, and when the third instructor arrived – leaving the larger group unsupervised, or supervised by the organiser who had to paddle out to them – the kayaker described having to be held in her craft by that instructor.
She was treated by two ambulance paramedics on her arrival back at Bulloch harbour, and recalled they were concerned with the amount of sea water she had swallowed.
The larger group drifted towards rocks, and the organiser paddled out to meet them. The report quotes a participant in this larger group recalling that when they disembarked on the rocks, an Irish Coast Guard officer instructed them to wait where they were, and to get onto a lifeboat which would be along shortly.
“This instruction.... was countermanded by the organiser who instructed them to make their way over the rocks, on foot,” the report states.
The investigation was told that another participant in the large group asked the Irish Coast Guard officer and the organiser “to stop giving conflicting orders as it was confusing”.
“This participant’s recollection was that she would have preferred to follow the directions of the Irish Coast Guard, as she was not happy about climbing over the rocks as she did not have proper footwear and she was anxious and fearful about slipping”.
“According to this participant, the organiser was adamant that the large group should climb over the rocks and the large group duly did so, without incident,” it says.
“They were unable to access a gate through a wall at the top of the rocks and had to make their way around the wall onto other (less slippery) rocks and then onto a flat shore where they were met by the Irish Coast Guard officer,” it says.
It says the organiser took issue with the Irish Coast Guard officer’s use of the word “hypothermia” in a radio report..
The report says that “as no records were made available, it has not been possible to determine what contingency planning was in place”.
It says that the forms signed by any of the participants on the tour were not provided to the investigator.
“According to one participant, she completed a form for her first excursion with the organiser a month previously but did not complete a second for the tour while the other participant does not recall completing any form,” the report says.
“ The form contains a detailed purported waiver of any liability on the part of the organiser. It is not the function of this report to comment on its legal validity,” it says.
The report also notes that “a waiver of liability form is not a substitute for the proper assessment of conditions and participants in a sporting or recreational activity on the water”.
The organiser, who was not one of the instructors, denied that one of the participants was in the water for 40 minutes.
The organiser stated of this participant that “on the 13 September we had a client who was not keen to get back into her kayak and who was feeling tired”.
“She was eventually returned to her kayak with the help of three instructors. If one floats in the sea, the effect of wind and water will carry you somewhere. That is the nature of floating in the sea. It doesn't mean that the conditions were inappropriate,” the organiser said.
The report also quotes the organiser as saying “one woman capsized more than once and needed some convincing to get back into her kayak. I have no wish to embarrass anyone and I don't see the need to say any more other than she was eventually returned to her kayak, and that she was not in the water for 40 minutes, though she was in the water for longer than usual”.
It also says there appears to be no record of any communication over VHF between the tour group and the organiser or instructors, such VHF “traffic” as is recorded on the Irish Coast Guard SITREP and report exchanged between the emergency and rescue services and the fisherman to coordinate the operation.
The report notes several draft reports preceded the final report, and changes were made “where they were warranted”.
It says the organiser detailed her own qualifications, stating “I am a level 4 instructor and hold the highest level skills award which is level 5”. She also said she is a tutor and can train and assess instructors.
It said that the organiser “does not consider regard should be had to CI, as she asserts that the current awards are “not fit for purpose for tour guiding as opposed to providing more in depth instruction”.” It says the organiser stated that a capsize drill is carried out at the harbour, but “no information has been provided as to who gave this instruction for this tour, nor as to what the content was on the date in question”.
It quotes one participant as stating no capsize drill took place.
It says that during the course of the investigation, the organiser of the tour was asked to provide certain records within the meaning of Section 30(1) the 2000 Act and to provide any additional information relating to the incident. It says “no such records or additional information were made available, over and above various statements about the incident made by the organiser in written exchanges in which she raised a number of issues.
The report says that on December 18th, 2020, the organiser wrote to the deputy director of the Irish Coast Guard requesting the “retraction, withdrawal and correction of the IRCG SITREP” for the incident.
The report makes a number of recommendations in relation to more effective delivery of the Code of Practice safety content, and says “consideration should be given to the establishment of a directory of commercial providers of coastal sea and river paddle facilities”.
The report says “consideration should be given to how best to enhance safety standards within the commercial paddlesport provider sector, including whether a mandatory registration or licencing scheme which requires the registration of instructors and their qualifications should be introduced”.
It says “consideration should be given to a mandatory requirement that commercial providers of coastal sea kayaking facilities register in advance with the local Coast Guard to ensure that the rescue services are aware, in advance, of the group’s itinerary, departure and return times, as well as numbers in the group”.
It says mandatory use of suitably licensed VHF radios by commercial providers of coastal sea kayaking facilities should be considered.
It says that CI in conjunction with Sports Ireland should “consider establishing a programme” to facilitate it in “establishing a scheme for the mandatory audit of safety policies and practises in clubs in collaboration with related sport national governing body, and, insofar as it is possible, the audit of instructors in commercial paddlesport providers”.
It says CI should consider “whether a safety audit and compliance system could be developed within its instructor training and registration system so that registered instructors have training in relation to safety requirements including those in the Code of Practice and Marine Notices, and so that CI could better contribute to safety through its regulation of its accreditation and registration system”.
The 240-page report includes lengthy appendices exchanges of communications between the organiser and the investigator. The report is downloadable from the MCIB website here
