Following is an edited version of the review which was conducted by Ken Day, Vice President. Report Date: 10 November 2009
Date of incident
11 October 2009
There were five participants: David Fisher (Trip Leader), Paul Loker, Bruce McNaughton, John Piotrowski, Michael Steinfeld
An overnight club trip to Broughton Island. On the return leg, Michael entered Cons Cleft alone, capsized, suffered a scalp wound and was successfully rescued using the combined skills of all the other participants. Michael didn’t require immediate external medical support but on return to Sydney he received three stitches to his scalp.
Cons Cleft is more commonly known as Conspicuous Cleft and is a feature of Looking Glass Island which is within 100 metres of Broughton Island. The parts of Looking Glass Island that are closest to Broughton Island are surrounded by rocky beaches and gauntlets. This area would not be accessed by motor boats and with big seas running can be quite treacherous. The cleft itself is about 3-6 m wide and 75 m long.
This report has been compiled from the NSW Sea Kayak Club Incident Report Form submitted by the Trip Leader and individual feedback from trip participants.
The group left Broughton Island after an informal and relaxed briefing. David, the trip leader, and Paul left the beach with the intention of checking the cleft to see if it was safe to paddle through. Bruce and John believed that this was the plan.
As the group approached the cleft Michael was out in front of the group and continued to paddle into the cleft whilst the others assembled near the entrance. With the sea conditions and waves washing a couple of metres up the wall of the cleft, David and Paul decided they would go through the cleft. Bruce and John decided to go around the island. David and Paul waited for a large set to pass before entering the cleft.
Michael decided to enter the cleft as it had appeared calm for the minute or so before he entered.
Michael had made it about two-thirds of the way through when a large wave picked up his kayak and carried it towards the southern wall of the gauntlet. It tipped the kayak on its side close to the wall and Michael fell in. Michael didn’t think about rolling because it happened on his wrong rolling side and he knew he had to get out fast to avoid falling into the shallow water beyond the wave.
Michael’s difficulty started when he was sucked backed in the same direction as he had entered the cleft. He thought he would just be pulled out by the waves. He grabbed his kayak thinking that he did not want to let go because it would give support while waiting to be rescued.
Michael tried to get his kayak towards the entrance but with each wave he had problems controlling the kayak. He now wonders whether he should have let go of the kayak and swum out. Michael remembers a large wave coming and lifting him up onto the side of the rocks and banging his head. Michael was aware that he could get knocked out.
David and Paul entered the cleft to find Michael in the water holding his kayak, bleeding from the back of his head. They agreed that David should move further out of the cleft as there was no room for three kayaks in the narrow turbulent area. Paul attempted to drag Michael and his kayak out of the wave area with him holding onto Paul’s rear toggle. There was too much drag with Michael’s inverted kayak having the sail and paddle bag hanging free, so Paul suggested Michael let go of his kayak.
After being tossed around repeatedly Paul also capsized. As he wasn’t sure of Michael’s condition he decided to wet exit. Paul thought that if needed he could be of more assistance to Michael in the water. They then swam partly out of the cleft supported by Paul’s kayak.
At this time David turned around to see both Michael and Paul in the water. David gave his towline to Paul who connected it to his kayak. David then started to tow Paul’s kayak, Paul and Michael out of the cleft. David asked John to help by connecting his towline to David’s boat to assist with the tow. John’s towline was in his day hatch and it took too long to get it out so David proceeded with the rescue without the additional towline.
Once Michael was out, David told John and Bruce to take him to the nearest beach. The tow was about 600 metres to a rocky beach.
Both David and Paul paddled back around the island to retrieve Michael’s kayak which had floated near the mouth of the cleft. David and Paul recovered one half of Michael’s spare paddle and towed Michael’s kayak to the rocky beach.
Michael’s injury was assessed as not requiring external medical support. First aid was applied and after suitable recovery time the group restarted the return journey. Michael was able to paddle unassisted to the landing point. There was little damage to the kayaks.
The weather was fine with slight winds. The sea state consisted of 2-2.5 metre swells from the SSE/SE. There were large and long period swells in the week prior to the trip. There were large infrequent wave sets paddling to Broughton Island.
All trip participants’ kayaks were fitted to the club’s Grade 3 standards. Michael had a VHF radio; the other participants had mobile phones.
Michael was in the water for about 45 minutes from capsize to landing on the beach and was dressed for immersion. That is, he wore long 2-3 mm neoprene long pants, an insulated top with a singlet wetsuit top which helped protect him from hypothermia.
Review of Incident
Some participants had their tow ropes in their day hatches. This resulted in increased time to conduct the rescue.
Michael’s sail wasn’t secured properly and became loose (still connected to the kayak), which increased the difficulty in carrying out the rescue. Michael’s spare paddle also came free from the boat and only one half was eventually recovered.
In the pre-trip briefing there was some discussion about entering the cleft; it was decided that the decision to enter the cleft would be made once the group was more familiar with the local current conditions. On the way to Broughton Island, it was decided not to enter the cleft due to the wave height. Prior to departing on Sunday there was some discussion about the return trip plan. This included some discussion about Cons Cleft although nothing specific was discussed in terms of the decision to enter.
On approach to the cleft, four of the group stopped to observe the conditions whilst Michael paddled ahead of the group and entered the cleft. David did not signal Michael to enter or not enter.
The remainder of the group agreed to split up with David and Paul entering the cleft and John and Bruce deciding to paddle around the island.
Considering the situation once Michael was found, it appears the group communicated well. Getting Bruce and John to get Michael to shore was probably the best choice due to Bruce’s first aid experience and David and Paul’s paddling skills.
There was only one VHF radio among the group, carried by Michael. The area of the trip is covered by Volunteer Coastal Patrol; the signal is weak at water level towards the island. There is a marine VHF base station on Broughton Island that could have been used to call for assistance if required. David distributed laminated maps to all participants which had emergency contacts printed on it. There is limited mobile phone coverage available on Broughton Island.
Injury to people should always take priority over recovering equipment. Whilst this decision may result in lost or broken equipment it must be the highest priority.
The decision to enter
Michael decided to enter the cleft as he had been through it before a number of times when there was little swell. He did not discuss his decision to enter with anyone. Michael entered the cleft at the wrong time without a proper consideration of oncoming large sets which were a feature of the weekend.
Trip participants must understand that the Trip Leader is ultimately responsible for the conduct of the trip. This is important where a participant may have better skills and would attempt something that the leader would not attempt (either as an individual or as a Sea Leader). It is also important that participants make their decisions based on the direction of the Trip Leader, the skills of the group and lastly on the skills of an individual in a group.
On approach to the cleft it should have been apparent to the group that they were about to change the level of risk associated with the paddle and conducted a rapid risk assessment. This should have consisted of watching the conditions in order to decide whether or not to proceed. Once the decision to proceed was made, a risk review and mitigation plan should have been conducted. This would have included:
- group order to enter the cleft;
- plans if something goes wrong;
- requirement to wear helmets;
- plan for the largest wave that may come through;
- review of chain of command; &
- check of equipment.
Inside the cleft
Michael may have avoided injury if he had left his kayak and swum out of the cleft. In the open ocean or any significant distance from shore (more than about 50 metres) kayakers should stay with their kayak. The kayak provides additional buoyancy and is easier to find by search and rescue organisations. Michael also could have been jammed between his kayak and the wall by a wave, which could have resulted in serious injury.
Michael did not use his whistle to attract attention. Had he done so it may have reduced the time to start his rescue therefore avoiding his injury. No helmet was worn by any participant.
Rescuing someone almost always put the rescuers at risk. Before entering a rock garden or gauntlet or undertaking something that increases the risk of damage to a kayak or personal injury, a paddler should discuss rescue options with other paddlers. They should assume that no one in the group will be able to rescue them. They may find themselves having to swim out of a gauntlet, leaving their boat behind.
Bruce and John applied first aid to Michael. Once treated and the kayak recovered Michael announced he was ready to recommence the return journey. It was agreed to allow more time before starting the return trip. This allowed more time for Michael to settle down mentally and physically, allowed time for other symptoms such as concussion to appear. It also gave all participants the time to discuss what had happened, question what they did and talk about things they may have done differently with more time.
The incident occurred because Michael was too hasty to enter the cleft without consideration of the risks relative to his abilities and equipment. David, as Trip Leader, could have provided a more detailed briefing before leaving Esmeralda Cove to ensure that it was clear that the group would stop before the cleft and the Sea Leader would decide whether to enter the cleft.
Michael was lucky that his injury wasn’t life-threatening and grateful that other participants in the group put themselves and their equipment at risk to rescue him.
The sequence of the recue was appropriate, with reasonable tasks being allocated to the appropriately skilled participants.
- Whilst members should be encouraged to improve their skills, any activity such as paddling in rock gardens and gauntlets which require special skills and a higher level of risk should only be done with the trip leader’s consent and knowledge. The trip leader will be unlikely to consent unless he/she is confident that they have the ability and resources at hand should a rescue be needed.
- Large infrequent swell sets must be factored into risk planning. Among other things, Michael should have waited and observed the swell before tackling the gauntlet.
- Additional emphasis should be placed on the importance of being able to rescue someone quickly and deploy tow lines during training and club trips. In practice most people who require rescue do so in difficult conditions when accessing a day hatch adds risk to both the rescuer and rescuee.
- Additional emphasis should be placed on securing equipment on kayaks to avoid the post-rescue activity of collecting gear.
- If there is limited safety or communications equipment in a group, each member of the group should know who has it and have at least some idea of how to use it.
- Trip Leaders are reminded to conduct full trip briefings no matter who is on the trip and to obtain agreement that participants won’t go off into increased risk areas (or anywhere) without full group discussion, planning, etc.
- No changes are required to NSWSKC policies and procedures.
- An excerpt of this incident review should be published in the magazine so that all members can benefit from the lessons learnt from this event.