Marine Accident Investigation Branch
Accident Investigation Report 14/2024
Read our marine accident investigation report, which includes what happened, subsequent actions taken and recommendations:
Summary
On 8 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.
Safety Issues
-
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.
Statement from the Chief Inspector of Marine Accidents
Recommendations
The Local Government Association has been recommended (2024/138) to bring this report to the attention of local authorities and to consider the role of local government in overseeing charitable waterborne activities.Recommendations have been made to the South West Lakes Trust (2024/139-143) concerning the maintenance regime and operation of boats used by wheelchair users. Recommendations have also been made to Burdon Grange care home (2024/144) about risk assessments for external activities and to The Wheelyboat Trust (2024/145-146) on the safe operation of wheelyboats and their use.