Report on the investigation of Wheelyboat with loss of lives

MAIB Report: Capsize of the recreational craft Wheelyboat 123 with the loss of two lives on Roadford Lake, Devon, England on 8th June 2022.

Summary:

On 8th June 2022, two wheelchair users lost their lives when a wheelyboat capsized on Roadford Lake, Devon, England. The wheelchair users were residents from a local care home who were participating in a day trip on the lake. When the wheelyboat capsized, the residents who were strapped into their wheelchairs were dragged to the bottom of the lake and drowned.

The MAIB investigation found that the wheelyboat had not been correctly maintained, allowing water to leak into the boat and making it unstable, which led to its capsize. The bow ramp seals were not subjected to regular inspection before use and had degraded, compromising the watertight integrity of the wheelyboat. The activity centre had not fully identified the risks or understood the unique needs of operating the wheelyboat with wheelchair users.

The key safety issues identified were:

  ♦ the watertight integrity of the bow ramp seal had degraded
  ♦ the wheelyboat capsized when water accumulated on the deck
  ♦ the risks of strapping wheelchair users in their chairs were neither considered nor mitigated
  ♦ both the activity centre and the care home assumed the other had knowledge about managing the activity for disabled  people.

Safety recommendations:

The Local Government Association is recommended to:

  ♦ Bring the report and safety issues to the attention of local authorities and to consider the role of local government in overseeing waterborne charitable activities. (The image shows the two who lost their lives.)

South West Lakes Trust is recommended to:

  ♦ Update the planned maintenance system used by its activity centres to include the specific maintenance tasks required by the manufacturers of the watercraft they operate, including boats used by disabled people.
  ♦ Employ a permanent member of staff dedicated to the maintenance and condition monitoring of all activity centre craft.
Train and educate instructing staff and any support staff in disability awareness through the attendance of recognised disability awareness training.
  ♦ Ensure instructors at its activity centres are educated in how to evaluate the weight and load distribution for users of craft designed for wheelchair users to ensure compliance with the design loading and manufacturer’s instruction.
  ♦ Revise driver assessment requirements for craft designed for wheelchair users to ensure drivers are equipped to recognise developing dangerous situations and take emergency action.

Burdon Grange care home is recommended to:

  ♦ Revise its risk assessments for activities provided by organisations outside of the care home environment to identify any hazards faced by the residents taking part in that activity and take steps to assure itself that appropriate risk mitigation measures are in place.

The Wheelyboat Trust is recommended to:

  ♦ Review the wheelyboat owner’s manual to ensure that guidance around wheelchair securing and the carriage of heavy, motorised wheelchairs is appropriate.
  ♦ Remind operators of wheelyboats supplied under a placement agreement of the need to submit annual condition notes and take action to ensure wheelyboats are being maintained in line with the owner’s manual and The Wheelyboat Trust’s requirements.

Andrew Moll OBE, Chief Inspector of Marine Accidents, told:

“Trips on the wheelyboat were beneficial for the continuing wellbeing and therapy of the residents of the care home; however, no-one had taken time …

… to question what had become custom and practice. Addressing this is not simple and may only be possible with a change in the law; however, the current situation is not something that should be tolerated.”