The organisation of the trip on the River Cleddau on 30 October 2021 was strongly criticised by the Marine Accident Investigation Branch MAIB.
Paul O’Dwyer, 42, Morgan Rogers, 24, Nicola Wheatley, 40, and Andrea Powell, 41, all died as a result of the trip in Haverfordwest, Pembrokeshire.
An inquest into their deaths was adjourned to allow investigations.
Mr O’Dwyer, from Port Talbot, Ms Rogers, from Merthyr Tydfil, and Ms Wheatley, of Pontarddulais, all died at the scene in Pembrokeshire.
Ms Powell, from Bridgend, died in hospital on 5 November 2021.
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MAIB chief inspector Andy Moll has now said the accident was “tragic and avoidable”.
floral tributes in Haverfordwest
Floral tributes were laid close to where the paddleboarders died
Mr O’Dwyer, an Army veteran, was one of the leaders of the excursion, organised by the Salty Dog Company of Port Talbot, and was travelling at the rear of the group.
The other leader survived the tragedy.
Nine paddleboarders set off at about 09:00 – there were two leaders, the wife of one of the leaders and six paying participants.
Four paddleboarders got into difficulties at a weir on the western Cleddau, outside County Hall.
They were trapped by “hydraulic towback, with no means of escape,” the report stated.
Although the leaders of the group were experienced paddleboarders, they had “no experience to teach novices on fast-flowing rivers”.
The MAIB said the leaders’ planning and preparation was inadequate and overlooked the extreme hazard posed by the weir.
They did not have adequate training, experience or qualifications to lead the group from Haverfordwest to Burton Ferry.
Martin Cavaney/Athena Pictures Crew in a boat on the River CleddauMartin Cavaney/Athena Pictures
Specially trained firefighters were involved in the rescue operation
Signs at the launch site and on the river were said to be inadequate, along with clothing and buoyancy aids.
The MAIB also criticised UK stand-up paddleboarding, saying safety messaging and training governance was inconsistent.
Several safety recommendations have been made by the authors of the report, including risk assessments from Welsh Water in collaboration with Pembrokeshire council and Milford Haven Port Authority.
MAIB Western Cleddau riverMAIB
The paddleboarders got into difficulties at a weir outside County Hall
Ch Insp Moll said stand-up paddleboarding was one of the “fastest-growing UK watersports”, with a 300% increase in numbers in recent years and urged participants to be aware of the risks.
“Firstly, wear the right equipment. Always wear a buoyancy aid,” he said.
“In certain conditions, weirs can develop treacherous hydraulic towbacks that can trap and drown you.”
Marine Accident Investigation Branch CCTV image of the Salty Dog owner sliding down the fish pass at the town weir
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