THE Marine Accident Investigation Board (MAIB) has this week released a report following its investigation of the capsize of a recreational craft on Roadford Lake.

During the incident on June 8, 2022, two wheelchair users lost their lives when the ‘Wheelyboat 123’ capsized. The wheelchair users were residents of Burdon Grange care home in Beaworthy 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 included the degradation of the watertight integrity of the bow ramp seal and the risks of strapping wheelchair users in their chairs being neither considered nor mitigated.

It was also reported that both the activity centre and the care home assumed the other had knowledge of managing the activity for disabled people.

Following the investigation the MAIB have made a number of 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.

South West Lakes Trust was told it must 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.

It needs to employ a permanent member of staff dedicated to the maintenance and condition monitoring of all activity centre craft and train and educate instructing staff and any support staff in disability awareness through the attendance of recognised disability awareness training.

The trust is also required to 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.

The MAIB added that a revision of driver assessment requirements for craft designed for wheelchair users is required to ensure drivers are equipped to recognise developing dangerous situations and take emergency action.

Burdon Grange care home must also 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.

Andrew Moll OBE, chief inspector of Marine Accidents, said: “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 properly consider the risks associated with taking the wheelchair users afloat, either before the accident or on the day itself.

“The condition of the wheelyboat had been allowed to deteriorate so water could enter it, and on the day no-one recognised the implications of carrying vulnerable people who were strapped into heavy motorised wheelchairs around a lake in an open boat. In short, no-one had their eye on the risk, and tragically Alison Tilsley and Alex Wood lost their lives.

"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. Charitable activities such as this seem to fall into a grey zone with no organisation or authority in a position of oversight. 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.”