Risk assessment

Established accident history

1991 – Collision involving an VIII from the Royal Free; severe injury to one crew member leading to helicopter evacuation and emergency thoracotomy. This accident occurred due to lack of organisation of boat flow in the marshalling area. Subsequent to this, the current chief umpire has largely been responsible for instituting the current marshalling system, reinforced by the PLA (Notice to Mariners).

1992 – 1996: no serious accidents but no accurate records;

(1997 – date: these races have been supervised by the current chief umpire.)

1997: no accidents;

1998: collision between two VIIIs in the marshalling area – failure of cox to keep adequate lookout – no injury;

1999: no accidents;

2000: near miss where VIII from another club ignored clear warnings and proceeded to cross the river against advice at about 30 seconds before the start;

2001: no accidents;

2002: no accidents;

2003: VIII steered into the PLA moorings as a result of bump; superficial injury to thorax in bow oarswoman; initially appeared more sinister and therefore evacuated by LAS from ULBH. Minor injury only. Need to highlight that losing cox must instruct his crew to pull away from bumps promptly particularly where river narrowed by obstruction or natural feature (PLA moorings, Brentford Ait, Oliver’s Eyot)

2004: near miss where cox steered boat in front of oncoming motor vessel (slow moving); to highlight need not to cross in front of any motor boat at 2005 coxswains’ meeting.

2005: Incident UH05-1; Coxswain sustained back injury (blunt musculo-skeletal) as a result of failing to acknowledge an inevitable bump; need to acknowledge early and avoid any physical contact to be stressed at 2006 races. Ongoing need to ensure adequacy of bowballs. Incident UH05-02; ladies’ crews drifted too far onto the Surrey side when stationary just after the finish. Need to ensure finish marshalling clearly identified to coxes in 2006 races, ensure launch 6 on correct station to ensure adherence to rules.

2006: no accidents - incident UH06-1 - marshalling launch overturned doing tight circle in shallow water - no injury and all equipment retrieved safely.

2007:  Incident UH07-3 – BL1 staker hit in the back by a backstay of the following RUMS boat.  Going into the water further than the waist will be discouraged. UH07-2 – Bow section of boat damaged following an early bump.  Emphasis made on aiming for an off-centre target on the boat ahead. Incident UH07-4 – Near miss when crew went across the course of the pleasure cruiser.  It has been made clear that this wasn’t appropriate and is potentially very dangerous.

2008: Incident UH08-3 – GKT staker hit by blade, minor injury.

2009: No incidents.

Risk Assessment Matrix¹ 

	Risk	Issues	Probability of accident	Likely severity	Risk estimation	Control measures
1	Novice and inexperienced coxes.   Lack of adherence to marshalling instructions (e.g at end of ladies’ race)	·          Coxswains fail to attend coxswains’ pre-race meeting ·          [Refer to issues set out in TRRC report on Dovehouse Pier incident in 2006]	Likely	Slight harm	Medium 7	·          UHBC sets basic minimum coxing experience criteria (min 30 outings); ·          attendance register at coxes meeting; ·          Coxswains and crews in general have had most of academic year to gain experience; ·          UHBC places emphasis on responsibilities of individual club captains to ensure compliance with marshalling instructions and attendance at coxswains’ meeting. ·          Ensure marshalling launches in correct position throughout marshalling and race.
2	Radio communication failure	·          Radio dead spot at head position. ·          Handset failure.	Unlikely	Slight harm	Low 4	·          Mobile phones as back-up ·          Launch 3 to keep out of dead spot ·          Direct contact (mobile telephone back-up) between L3, BM9 & BM10.
3	Inadequate launch availability	·      Borrowed launches. ·      Engine failure.	Unlikely	Slight Harm	Low 4	·          Minimum 10 functioning launches available at start of race ·          Reserve launch on standby at ULBH
4	Inadequate launch safety equipment	·      Borrowed equipment	Very unlikely	Moderate Harm	Low 2	·          Minimum 10 fully equipped launches at start of race; ·          Launch 9 designated safety launch; ·          UHBC to identify responsibility of individual club captains to provide equipment in line with British Rowing Row Safe
5	Medical facilities	·          Medical cover. ·          First aid kit.	Very unlikely	Extreme Harm	Low 3	·          President and Vice-presidents medically qualified; ·          Basic medical equipment provision, including oxygen
6	Medical evacuation	·      Difficulty for LAS ambulance to gain access. ·      Remoteness from primary evacuation route.	Very unlikely	Extreme Harm	Low 3	·          LAS outside of UHBC control ·          Designated primary evacuation route via ULBH ·          Secondary routes via Kew or TSSC (road); ·          Syon or UWBH (air). ·          BM10 to co-ordinate primary evacuation or designate secondary co-ordinator.
7	Watermanship of competitors proceeding to marshalling area	·      Failure of cox to keep adequate look-out ·      Inexperience of coxes ·Failure to adhere to CPRT ·Congestion up to crossing point	Likely	Slight harm	Medium 7	·          See 1 above; ·          Supervision by 10 launches; ·          Pre-race information to coxes ·          Provision of Port-hand buoys appears to help control risk by identifying correct navigation channel; ·          Launch 4 to control traffic build up towards crossing point.
8	Watermanship of competitors and external crews at revised crossing (PLA notice to mariners)	·      Crews attempting to cross too early ·      Crews failing to observe correct crossing point ·      External crews deliberately ignoring instructions ·      Navigation behind PLA moorings (note wooden post – new for 2008)	Likely	Slight harm	Medium 7	·          Crossing supervision by launches 3 and 4; PLA mooring supervision by launch 2 (wooden post new for 2008); ·          Pre-race information to coxes about wooden post (new for 2008); ·          PLA notice to mariners; ·          UHBC written/e-mail notification to other local clubs; ·          Warning to those deliberately ignoring instructions that report will be made to PLA/TRRC/own club
9	Supervision of marshalling areas	·      Failure to adhere to temporary navigation rules set out in PLA NTM 2010U1 ·      Crews rowing at firm pressure in congested area ·          Too many boats in marshalling area between crossing and PLA moorings ·          Navigation behind PLA moorings (note wooden post)	Likely	Slight harm	Medium 7	·          3 launches in  marshalling area; ·          Pre-race instruction to coxes; ·          Launch 2 to check depth for navigation behind PLA moorings if necessary and assess impact of wooden post (sufficient room between post and mooring for an VIII); ·          No firm pressure / racing starts in marshalling area; ·          Launches 3 and 4 to hold crews below crossing if excess congestion.
10	Turning of competitors onto the stream	·      Novice coxes ·      Failure of cox to keep adequate look-out ·      Failure of cox to get boat into correct in-shore area as a result of the turn ·      Failure of marshalling launch to supervise turning	Likely	Slight harm	Medium 7	·          Adequate supervision by marshalling launches 1 & 2; ·          Pre-race information to coxes; ·          Club captains to ensure proficiency of novice coxes
11	Landing at the start	·      Landing with the stream	Unlikely	Slight harm	Low 4	·          Coxes to practice landing with stream; pre-race information to coxes ·          Launches 1 & 2 to supervise second attempts.
12	Start sequence	·    Unobserved obstruction on course ·    Pleasure cruiser on course ·    Delay whilst waiting for powered vessels coming upriver (particularly likely at weekend) ·    Non-compliant external crew	Unlikely	Moderate harm	Medium 5	·          Chief umpire in charge of start sequence; ·          wait or abort start up to last few seconds if necessary if powered vessel/pleasure cruiser or non-compliant external crew on course; ·          Chief umpire to visually check whole of marshalling area and telephone/radio check with PLA Richmond Lock and BM 9 prior to starting sequence;
13	Injury to stakers	·      From blades of own boat or next boat ·      Inattention just after start ·      May go too deep into water	Unlikely	Moderate harm	Medium 5	·                  Stakers to go no further in than waist height; emphasis at coxes and marshals meetings. ·                  Must stand back and keep a good lookout.
14	Race start and course	·      Coxes’ attention drawn away from proper watermanship ·      Failure to keep adequate look-out ·      Failure to adhere promptly to PLA byelaws (2006/U15) & CPRT ·      Conflict with motor vessels (especially on Saturday) ·      Difficulty in communication between marshals and coxes	Likely	Slight Harm   (usually no conflict)	Medium 7	·          Pre-race information to coxes; ·          Ensure all coxes have key minimum competencies as assessed by club captains; specific requirement on all club captains to disclose problems with competency at previous UHBC committee meeting ·          Launch 3 (JM) will attempt to delay race start to avoid possible conflict in kew RZs with oncoming powered vessels ·          Launch provided for escorting powered vessels (launch 10), duties shared with launch 8 if large number of powered vessels ·          Launches equipped with adequate megaphone and flags;
15	Navigation in Kew Restricted Zone	·          Variation of standard rules set out in PLA NTM 2006/U15 by specific event NTM 2010/U1 – failure of coxes to adhere to changed rules ·          Potential narrowing of channel in RZ’s by oncoming powered vessels	Likely	Slight harm	Medium 7 (based on 2007 event)	·          Overtaking in Kew RZs only when safe (coxes’ meeting) ·          Launch marshals 5 & 6 (led by launch 5) have power to enforce ’line astern’ racing if conditions not safe (e.g. oncoming powered vessel) ·          Launch 10 to provide escort of powered vessel upriver (shared with launch 8 if excessive number of powered vessels)
16	Bumping	·          Physical contact possible ·          Possibility of personal injury - Inadequate bowball and/or foot restraints ·          Despondancy in losing crew; failure to keep an adequate lookout; ·          Difficulty where channel narrowed (PLA moorings, Brentford Ait, Oliver’s Eyot) ·          Effect of PLA Restricted Zones at Kew  (NTM 2006/U15) ·          Failure of crews to disengage promptly and likelihood of obstruction of fairway (especially in Kew RZs)	Likely	Slight harm (based on UHBC experience; although possibility of equipment damage)	Medium 7	·          Encourage early acknowledgement of bump to avoid physical contact of any sort (coxes’ meeting); ·          Marshals to inspect bowballs and adequacy of foot restraints of boats rowing in event (British Rowing rules of racing)  (BM8); ·          Marshals to target narrow channel areas (especially PLA moorings - launches 2 & 3); ·          Specific terms of NTM to permit overtaking in Kew RZs ·          Other rules of RZs not varied – to emphasise at coxes’ and marshals meetings ·          Possible need for launch marshals 5 & 6 to order ‘line astern’; revised bumping rules in this case in the Kew RZs (no overtaking, no technical bumps etc) – coxes’ meeting; ·          Losing (leading) cox must always move first to disentangle the bump – especially in the Kew RZs; ·          Crews must only stop in two designated areas on Surrey side of fairway (before and after Kew RZs), without obstructing either the fairway or the Surrey inshore zone (emphasis at coxes’ meeting) – launches 5,6,7,8 & 10
17	Race finish and turning	·          Failure to keep an adequate lookout ·          Failure to comply with CPRT ·          Potential obstruction of Surrey inshore zone (especially ladies’ crews turning after ULBH) ·          Failure to comply with requirements of Chiswick Bridge RZ (NTM 2006/U15) – men’s race	Likely	Slight harm	Medium 7	·          Marshalling launches 7,8 & 10 to ensure boats able to turn safely away from bridges and RZs; ·          Procedure for turning in pre-race information to coxes (coxes’ meeting); including discussion about Chiswick Bridge RZ
18	Watermanship of returning crews	·          Failure to adhere to CPRT, especially in Surrey in-shore zone; ·          Failure to give way to vessels on fairway when crossing back to ULBH	Unlikely	Slight harm	Low 4	·          Navigation back to ULBH in coxes’ meeting, launch 7 to supervise crossing of crews back to ULBH (assisted by other launches as available) at water outfall.