Poor safety culture at Limerick rowing club contributed to Amy Mulcahy's injuries
Amy Mulcahy and her mum Sharon. Amy became submerged underwater after the rowing club's boat capsized when her hair became entangled with one of the boat’s rowlocks. Photo: Press 22
The poor safety culture at a Limerick rowing club was a contributory factor in an incident in which a 12-year-old girl suffered life-changing injuries when she became trapped under a rowing boat after it capsized on the River Shannon two years ago, an investigation has found.
However, a report by the Marine Casualty Investigation Board said contributory and causative factors for the incident extended beyond the decisions of the coaches on the day “to the higher levels of club culture” and the ethos of the sport’s governing body, Rowing Ireland.
It said the absence of a viable safety culture within Athlunkard Boat Club in Limerick and its “complacent and hands-off” attitude towards safety during activities on the river contributed to the incident while the collective inexperience of the young crew was also a risk and contributory factor.
The MCIB found another factor was the lack of effective advice and encouragement in safety matters by Rowing Ireland since 2017 to nurture a safety culture in the club.
The incident occurred on February 23, 2019, when a group of five young rowers, aged 12-13 years, from the club were on a training session in an Olympic-style Quad rowing boat.
The boat capsized after hitting some midstream supports of the salmon weir at Thomondgate in Limerick at around 10.15am after the crew was unable to turn it around to go back upstream. Four of the crew were rescued from the water by their coach who was accompanying them in a safety boat.
The other crew member – novice rower Amy Mulcahy from Annacotty in Limerick – became submerged underwater when her hair became entangled with one of the boat’s rowlocks. She required hospitalisation after being freed by a crew from the Limerick City Fire and Rescue Service who were on a training exercise in an inflatable boat on the river at the time.
Correspondence from the coach and Rowing Ireland show both parties took strong issue with various findings of the investigation.
The MCIB said the absence of a plan for what was a routine training session resulted in the rowing boat operating with the coach and safety boat in isolation and some distance from assistance from other club boats on the river.
It found the rowing club had no standard procedures for carrying out a risk assessment for training sessions.
MCIB inspectors said the club had provided no evidence of a viable safety culture but noted that officials claimed their safety standards were no different to many other rowing clubs.
The MCIB claimed there was a “complacent attitude” towards training sessions “where nothing was expected to occur out of the ordinary".
It said the hazard presented by Thomond Weir had been underestimated by the coach, the club’s safety officer and other officials.
The 148-page report found the safety boat also lacked many basic pieces of equipment recommended in guidelines published by World Rowing including a knife and first aid kit, while it also had a lack of spare lifejackets.
It observed that the safety boat was also only designed to carry four persons which meant it was overloaded after rescuing four crew members.
The coach stated the hazardous nature of Thomond Weir had never been communicated to him, while the club said it was known to be a hazard and only for experienced rowers in favourable conditions.
However, the MCIB observed: “The crew were young, inexperienced, frightened and uncoordinated and the Quad would be difficult to manage in a fast flow even with an experienced crew.”
The investigation found that various guidelines issued by rowing’s national and international governing bodies were ambiguous about manning levels for coach and safety boats. Rowing Ireland told the MCIB that it does not have oversight over club training standards which are the responsibility of individual clubs.
The report said there were poor communications between the national governing body and Athlunkard Boat Club on the dissemination of safety advice. It noted that Rowing Ireland believes its mandate is only to encourage and offer advice on safety issues.
The sports body strongly refuted the suggestion by Athlunkard Boat Club and its coach that it had a compliance role with regard to safety at club level.
However, the MCIB said it was reasonable to deduce that “a more dynamic, proactive and consistent policy” by Rowing Ireland since its initial efforts in 2017 to disseminate safety documentation and encourage the nurturing of a safety culture within clubs might have resulted in Athlunkard Boat Club having a better safety culture in 2019.
It said the strong opposing views that Rowing Ireland and the club had of their respective roles and responsibilities should lead the governing body to assess the effectiveness of its own contribution to the improvement of safety.
The MCIB said the fact that novice and trainee rowers using Olympic style rowing boats were not required to wear personal flotation devices (PFDs) added to the difficulties faced by the coach in his initial efforts to free the trapped rower as he was distracted by other crew members floating downstream without any PFDs.
The board said it was not clear if the legislation which waives the mandatory wearing of PFDs for Olympic rowing boats should be interpreted to also apply to very junior trainee rowers. It called on the Department of Transport and Rowing Ireland to consider what was the intention of the relevant regulation.
The MCIB issued 16 safety recommendations to Athlunkard Boat Club to address concerns raised in its report and a further 15 recommendations to Rowing Ireland.
Among 10 recommendations directed at the Minister for Transport, Eamon Ryan, was one for an immediate review of the Code of Practice for the safe operation of recreational craft to consider amending rowing boat crew standards in relation to personal protective clothing and hair length because of the dangers hypothermia and entanglement posed to rowing crews.
