Wayne Rodgers
PFD Report
Partially Responded
Ref: 2019-0105
Coroner's Concerns (AI summary)
Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment requirements and racing abandonment criteria.
View full coroner's concerns
1) I was informed that during the course of Cowes Week Sailing Festival that there are approximately 7,000 competitors who travel to Cowes on the Isle of Wight to participate in the various events. In this instance, it was fortunate that an ambulance was available to convey the casualty to the hospital as an emergency. However, there are a finite number of ambulances on the Isle of Wight, and they are often overstretched to carry out routine work, without the possibility of an incident happening during this Sailing Festival.
2) During the course of the evidence it was discussed with the Deputy Queen’s Harbour Master as to whether it would be a good idea for the organisers of the Cowes Week Sailing Festival to consider employing the services of a private ambulance service, such as the St John’s Ambulance Service, and paramedics, to be on site at Cowes and available at the harbour immediately were there to be an incident involving any of the competitors from the Festival thereby making the event a safer one.
3) Having considered the report into the incident from the Deputy Queen’s Harbour Master, I would endorse that consideration be given to the pre-positioning of Automated External Defibrillators (AEDs) afloat and ashore.
4) A review needs to be carried out of the Crisis Management Plan, with an emphasis on monitoring and recording of safety channels and manpower coordination for incident response.
5) A review needs to be carried out of the published list of mandatory safety equipment, including mention of readily accessible safety knives.
6) A review needs to be carried out of the criteria for abandoning racing in the event of a major incident.
7) Consideration should be given as to the benefits and risks of using continuous sheets on the jib and spinnaker. This could be extended to several other classes of dayboat and dinghy which often adopt the same configuration.
2) During the course of the evidence it was discussed with the Deputy Queen’s Harbour Master as to whether it would be a good idea for the organisers of the Cowes Week Sailing Festival to consider employing the services of a private ambulance service, such as the St John’s Ambulance Service, and paramedics, to be on site at Cowes and available at the harbour immediately were there to be an incident involving any of the competitors from the Festival thereby making the event a safer one.
3) Having considered the report into the incident from the Deputy Queen’s Harbour Master, I would endorse that consideration be given to the pre-positioning of Automated External Defibrillators (AEDs) afloat and ashore.
4) A review needs to be carried out of the Crisis Management Plan, with an emphasis on monitoring and recording of safety channels and manpower coordination for incident response.
5) A review needs to be carried out of the published list of mandatory safety equipment, including mention of readily accessible safety knives.
6) A review needs to be carried out of the criteria for abandoning racing in the event of a major incident.
7) Consideration should be given as to the benefits and risks of using continuous sheets on the jib and spinnaker. This could be extended to several other classes of dayboat and dinghy which often adopt the same configuration.
Responses
Action Planned
Cowes Week Limited is discussing additional ambulance support, reviewing AED placement, reinforcing the necessity of having a sharp knife on board, and reviewing criteria for abandoning racing. The organisation will have independent radio operators to monitor safety communications and will address continuous spinnaker sheets in their safety booklet. (AI summary)
Cowes Week Limited is discussing additional ambulance support, reviewing AED placement, reinforcing the necessity of having a sharp knife on board, and reviewing criteria for abandoning racing. The organisation will have independent radio operators to monitor safety communications and will address continuous spinnaker sheets in their safety booklet. (AI summary)
View full response
Dear Ms Sumeray,
I am in receipt of your report after your inquest with regards to the fatality on board Legs 11 during Cowes week 2018, (Mr Wayne Andrew ROGERS) and I respond on behalf of Cowes Week Limited, the organisers of the event.
I confirm our acknowledgement of the recommendations outlined in the report and I can confirm that we are implementing the actions outlined as follows ;
1) With regards to the additional ambulance support proposal, this is something that we are discussing internally and on which I will revert to you on.
2) As above.
3) With regards to Automated External Defibrillators, this is under review. It is not practical to have AED’s on small rescue craft which are subject to being wet much of the time and we only have a limited number of bigger control vessels with dry cabins during the week. We will review the options of putting AED’s on some of those boats but our initial thoughts are that a delay in returning a casualty to shore are highly unlikely to make stopping off at a larger committee boat on the water practical . There are already several AED’s within 90 seconds of the Trinity Landing pontoon (the emergency drop off point for on water causalities) and we will look at making one available directly on the pontoon as well.
4) I can confirm that we have fully taken on board all of the recommendations in the investigative report with regards to monitoring and recording safety channels as well as the manpower requirements.
Cowes Week Ltd Regatta House, 18 Bath Road, Cowes, Isle of Wight PO31 7QN, UK Telephone - Office: +44(0)1983 248 002 Fax: +44(0)1983 295329 Email: Laurence.mead@lendycowesweek.co.uk Website: www.lendycowesweek.co.uk VAT Registration number: 918 1037 39
From this year’s regatta those people monitoring the radio for safety communications (all highly trained) will be independent of those radio operators dealing with race matters from competitors.
5) Some of the recommendations are outside our control in terms of delivery (as an example the fact that all boats should carry suitable knives) but despite that being the case we will be making the recommendations known to our competitors, both through our sailing instructions (where appropriate) and our safety booklet where appropriate. There are no accepted standards for how many knives should be carried, in what locations, on what size of boat, so we think it would be difficult for Cowes week to lead the way in trying to define that. Nonetheless the necessity to have a sharp knife on board, whilst being known to most sailors, is something that we will reinforce.
6) We are reviewing again the criteria for abandoning racing in the case of strong winds and / or an incident. We feel this worked well in 2018 but further work is being undertaken in this regard to ensure that any lessons learned are taken on board. In particular we are looking at alternative drop off points for casualties on the mainland, if that is nearer to an incident location or is an easier location to reach in certain wind conditions. This was not the case in this instance.
7) We are making known the issue that continuous spinnaker sheets may have played a part in this incident and this will be addressed in our safety booklet going forward.
I hope this clarifies our responses to last year’s tragic accident to your satisfaction
I am in receipt of your report after your inquest with regards to the fatality on board Legs 11 during Cowes week 2018, (Mr Wayne Andrew ROGERS) and I respond on behalf of Cowes Week Limited, the organisers of the event.
I confirm our acknowledgement of the recommendations outlined in the report and I can confirm that we are implementing the actions outlined as follows ;
1) With regards to the additional ambulance support proposal, this is something that we are discussing internally and on which I will revert to you on.
2) As above.
3) With regards to Automated External Defibrillators, this is under review. It is not practical to have AED’s on small rescue craft which are subject to being wet much of the time and we only have a limited number of bigger control vessels with dry cabins during the week. We will review the options of putting AED’s on some of those boats but our initial thoughts are that a delay in returning a casualty to shore are highly unlikely to make stopping off at a larger committee boat on the water practical . There are already several AED’s within 90 seconds of the Trinity Landing pontoon (the emergency drop off point for on water causalities) and we will look at making one available directly on the pontoon as well.
4) I can confirm that we have fully taken on board all of the recommendations in the investigative report with regards to monitoring and recording safety channels as well as the manpower requirements.
Cowes Week Ltd Regatta House, 18 Bath Road, Cowes, Isle of Wight PO31 7QN, UK Telephone - Office: +44(0)1983 248 002 Fax: +44(0)1983 295329 Email: Laurence.mead@lendycowesweek.co.uk Website: www.lendycowesweek.co.uk VAT Registration number: 918 1037 39
From this year’s regatta those people monitoring the radio for safety communications (all highly trained) will be independent of those radio operators dealing with race matters from competitors.
5) Some of the recommendations are outside our control in terms of delivery (as an example the fact that all boats should carry suitable knives) but despite that being the case we will be making the recommendations known to our competitors, both through our sailing instructions (where appropriate) and our safety booklet where appropriate. There are no accepted standards for how many knives should be carried, in what locations, on what size of boat, so we think it would be difficult for Cowes week to lead the way in trying to define that. Nonetheless the necessity to have a sharp knife on board, whilst being known to most sailors, is something that we will reinforce.
6) We are reviewing again the criteria for abandoning racing in the case of strong winds and / or an incident. We feel this worked well in 2018 but further work is being undertaken in this regard to ensure that any lessons learned are taken on board. In particular we are looking at alternative drop off points for casualties on the mainland, if that is nearer to an incident location or is an easier location to reach in certain wind conditions. This was not the case in this instance.
7) We are making known the issue that continuous spinnaker sheets may have played a part in this incident and this will be addressed in our safety booklet going forward.
I hope this clarifies our responses to last year’s tragic accident to your satisfaction
Sent To
- Cowes Week Limited
- Resilience and Response, Isle of Wight NHS Trust
- Jubilee Stores
Response Status
Linked responses
1 of 5
56-Day Deadline
9 May 2019
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14th August 2018 I commenced an investigation into the death of Wayne Andrew ROGERS, aged 62. The investigation concluded at the end of the inquest on 6th March 2019. The conclusion of the inquest was “Accidental Death”. The medical cause of death was found to be: 1a Drowning 1b 1c II
Circumstances of the Death
1) Wayne Andrew ROGERS was born on 23rd March 1956. At the time of his death he was 62 years old and was a retired Accountant.
2) On Friday 10th August 2018, Wayne Andrew ROGERS was participating in an R.S. Elite Class Race at Cowes Week in the Solent. Mr ROGERS was a very experienced sailor having sailed for approximately 50 years.
3) Mr ROGERS was a member of a crew of three in a boat called “Legs Eleven” with two other very experienced sailors. He was trimming the spinnaker sitting in the middle of the boat. The owner of the vessel was the skipper and the third member of the crew was navigating at the front of the boat.
4) The race commenced at approximately 11.05 hours. The weather conditions were forecast for the race to be 12-18 knots from the south-west. At the time of the incident, the recorded windspeed had increased to 26 gusting 29.6 knots.
5) The race commenced from the Royal Yacht Squadron start line in an easterly direction. Initially the spinnaker was set. As the race progressed on the course, the wind increased and became very gusty. There was one really big gust which caused the crew of the “Legs Eleven” to lose control when the boat broached. This caused Mr ROGERS to be thrown across the boat into the water. It is believed that this happened at 11.25 a.m.
6) When Mr ROGERS had been inside the boat, he was manually holding onto the spinnaker sheet which is a thick piece of rope used to trim the spinnaker. It is believed that Mr ROGERS was still holding onto this rope as he fell into the water.
7) At the point at which the boat broached, the skipper also partially fell into the water, but he managed to climb back into the boat. Once back in the boat, he tried to take control and stop the boat by turning into the wind, however he was unable to do so as Mr ROGERS appeared to be still holding onto the spinnaker sheet whilst in the water, thereby preventing the boat from manoeuvring.
8) The spinnaker sheet appeared to be fouling the tiller. The crew shouted for Mr ROGERS to let go of the rope, until they realised that it was, in fact, caught around his ankle, and he was being dragged behind the boat trapped by his ankle. Subsequent calculations estimate that Mr ROGERS was being dragged in this manner for approximately a minute before a member of the crew from another boat who had been racing and had spotted this incident managed to jump into the water beside Mr ROGERS and cut him free.
9) Immediate attempts to conduct CPR on Mr ROGERS were carried out. A Mayday call was made on the VHF emergency channel 16 requesting assistance for an unconscious casualty. A rescue rib arrived, the crew were in contact with the coastguard. Minutes later, the RNLI arrived and took Mr ROGERS back to Trinity Landing at Cowes. Mr ROGERS was subsequently transferred by emergency ambulance to St Mary’s Hospital, Newport, where he was pronounced dead at 13.10 hours.
2) On Friday 10th August 2018, Wayne Andrew ROGERS was participating in an R.S. Elite Class Race at Cowes Week in the Solent. Mr ROGERS was a very experienced sailor having sailed for approximately 50 years.
3) Mr ROGERS was a member of a crew of three in a boat called “Legs Eleven” with two other very experienced sailors. He was trimming the spinnaker sitting in the middle of the boat. The owner of the vessel was the skipper and the third member of the crew was navigating at the front of the boat.
4) The race commenced at approximately 11.05 hours. The weather conditions were forecast for the race to be 12-18 knots from the south-west. At the time of the incident, the recorded windspeed had increased to 26 gusting 29.6 knots.
5) The race commenced from the Royal Yacht Squadron start line in an easterly direction. Initially the spinnaker was set. As the race progressed on the course, the wind increased and became very gusty. There was one really big gust which caused the crew of the “Legs Eleven” to lose control when the boat broached. This caused Mr ROGERS to be thrown across the boat into the water. It is believed that this happened at 11.25 a.m.
6) When Mr ROGERS had been inside the boat, he was manually holding onto the spinnaker sheet which is a thick piece of rope used to trim the spinnaker. It is believed that Mr ROGERS was still holding onto this rope as he fell into the water.
7) At the point at which the boat broached, the skipper also partially fell into the water, but he managed to climb back into the boat. Once back in the boat, he tried to take control and stop the boat by turning into the wind, however he was unable to do so as Mr ROGERS appeared to be still holding onto the spinnaker sheet whilst in the water, thereby preventing the boat from manoeuvring.
8) The spinnaker sheet appeared to be fouling the tiller. The crew shouted for Mr ROGERS to let go of the rope, until they realised that it was, in fact, caught around his ankle, and he was being dragged behind the boat trapped by his ankle. Subsequent calculations estimate that Mr ROGERS was being dragged in this manner for approximately a minute before a member of the crew from another boat who had been racing and had spotted this incident managed to jump into the water beside Mr ROGERS and cut him free.
9) Immediate attempts to conduct CPR on Mr ROGERS were carried out. A Mayday call was made on the VHF emergency channel 16 requesting assistance for an unconscious casualty. A rescue rib arrived, the crew were in contact with the coastguard. Minutes later, the RNLI arrived and took Mr ROGERS back to Trinity Landing at Cowes. Mr ROGERS was subsequently transferred by emergency ambulance to St Mary’s Hospital, Newport, where he was pronounced dead at 13.10 hours.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.