Safety issues were not considered, and no-one took the time to properly consider the risks.
These are two of the findings of a Marine Accident Investigation Branch investigation into a boating accident in which two wheelchair users drowned.
The incident happened in June 2022, when a wheelyboat capsized on Roadford Lake in Devon, England.
The wheelchair users were residents from a local care home who were taking part 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.
No-one had their eye on the risk.
Andrew Moll OBE
In addition, the activity centre had not fully identified the risks or understood the unique needs of operating the wheelyboat with wheelchair users.
The report found that the risks of strapping wheelchair users in their heavy motorised wheelchairs around a lake in an open boat were neither considered nor mitigated.
In addition, both the activity centre and the care home assumed the other had knowledge about managing the activity for disabled people.
“In short, no-one had their eye on the risk, and tragically Alison Tilsley and Alex Wood lost their lives,” said chief inspector of marine accidents, Andrew Moll OBE.
“As well as the catalogue of failings highlighted by the report, the investigation has also uncovered a worrying lack of oversight which must be seen as an impetus for urgent action.”
Custom and practice
And he pointed out that charitable activities such as this seem to fall into a grey zone with no organisation or authority in a position of oversight.
On this occasion, this meant that no-one stepped in 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,” said Andrew.
The MAIB has recommended that the Local Government Association bring the issues to the attention of local authorities.
Recommendations have also been made to the activity provider, the South West Lakes Trust concerning the maintenance regime and operation of boats used by wheelchair users, to the care home and to The Wheelyboat Trust on the safe operation of wheelyboats and their use.
