Westwater Incident - A case study of a rafting accident on the Colorado River

A commercial rafting incident occurred on June 4th, 2015 on the Westwater section of the Colorado River in Utah. It resulted in a fatality. The purpose of this case study is to provide an actual scenario for students to study and to assist in accident prevention. It uses the rescue curve to frame the incident.

The following are some questions raised by the case study and video.
1) In terms of the rescue curve, Kathy’s attempt to self-rescue was unsuccessful. Should she have been able to get on top of the flipped raft?
2) Rescue by other rafters in your group is the next line of defense. Discuss the impact of spacing on the rescue or lack of rescue?
3) When does rescue mode begin? Should Cliff have waited nearly two minutes in the eddy before pursuing Kathy’s raft?
4) If you were the guide in Cliff’s raft, could you make “rescue mode” into an exciting activity for passengers? What would you do?
5) Use your favorite accident process model or barrier analysis to stimulate a discussion on accident prevention.
6) Last, if this case study is used to discuss negligence, was there a breach of duty. Note that this case was settled out of court and the plaintiff was pleased with the settlement.

[ridemrt]

That day, 2 people actually died holding on to that capsized raft as it floated for miles. "Charlie" was part of the commercial group but the other victim 27yrs old was on a private raft who was traveling closely behind the commercial group for safety. A day I will never forget. I have the GoPro footage from our boat, but I appreciate being able to see from other angles. Thank you for your breakdown

[travismickelson]

Every time I go rafting I make sure and stress with my group the importance of any time someone is in the water to assume that they are not OK. The group must always be working on safety. Any time anyone is in the water it is everyone's responsibility to get them out as soon as possible. I will not raf with some oars men that do not understand this.

[AssortedMeats]

I worked at a rafting company on the Arkansas river a few years ago, during a summer where the water was higher than it had been in 15 or so years. I originally came to be a raft guide, but decided I didn’t want to be the only one in charge if it came down to rescuing someone/everyone if we flipped. So I opted to work in the front and just go on the trips when I could.

There was a section of the river that was similar to that “room of doom” (not sure we had a name for it since it was record high water and a feature we don’t see often) and we flipped right before it. I planned to kick off the rock face so I didn’t get stuck in the eddy, but it sucked me down anyway. I’m certainly no pleb in the water and can usually take care of myself, and even after hearing the “safety talk” every damn day, I still ended up inhaling water from the shock of it. I managed to cannon-ball-starfish my way out of it after a minute getting chundered, but it honestly felt like sheer luck. It was harrowing and I can imagine how easy it would’ve been to have not made it out.

[jerrysmith]

I came upon this video at random.
Pretty sure I know that deceased rafter. I have a friend that died in a raft accident in 2015 on the Colorado. He was an all around remarkable good guy.

[sacjusticeforyou]

Excellent breakdown. Sadly, Cliff should have been in rescue mode as soon as Kathy’s raft flipped. Also, the boat spacing seemed distant considering that section of the run.

[paddlefaster]

I remember running this section back in the 90s. I was a triathlete at the time and in really good condition. The guide said he'd never seen the water as high as it was. He told me if we flipped to crawl across the bottom and not try to swim. Freaked me out when he said that having never rafted before. I asked him why he didn't tell the other people and he said because they wouldn't be able to do it. Not sure what to make of all that.

[seant]

If you've rafted this section, the roar of Skull Rapid as your approaching during high water is deafening.

[cycloneaction]

I was a guide for 12 years on the middle fork in Idaho. It was amazing the idiots outfitters employed as guides. They put grandmas in half inflated duckies and loose life jackets all the time. Its just dumb luck that more don't die from guide negligence. I've seen so many nasty swims. I had to get out, it drove me insane. I burnt out getting angry at frat boy guides.

[danbev]

If there is a flip - always, ALWAYS go to help! It’s important to have each other’s backs under any circumstances.

[Frisbieinstein]

In Skull Rapid there is a lateral current from the left. You have to start right and work over to the left.

[jimwright]

This video is way too short, and way too quick to place blame. As are most of the commenters.

Every boat in a string may flip. It’s the responsibility of each preceding boat to find a safe, secure place to assist in a potential rescue. The last boat in the string, the sweep, is designated to rescue swimmers from preceding boats. If it goes over, they are reliant upon the other boats. This is extremely important on big, difficult water.

The downstream boats, which should be safely eddied, are designated to “catch” or “chase.” Catch means picking up swimmers. You’re in catch mode until everyone is accounted for. Only then do you chase downstream to get the raft, gear, etc., but only if the incident is secured, i.e., you can rally everyone above the next rapid.

The guide who flipped the boat can be blamed for taking the wrong line, or for not running it properly. It happens. Male or female, weak or strong, experienced or not, it happens. The old saying says: “There are two kinds of boaters. Those who have flipped, and those who will.”

Go, and learn, and try, and fail, and cry before you blame.

[thepilgrim]

Few things here: firstly it was not mentioned how the guy drowned. It appears that he was past the major hydraulics and, as this was a commercial trip, I’m sure he had a certified pfd. Did he get hyperthermic? Heart attack? Was he injured during the flip? Did he strike a rock? Hit a strainer? Another hole? Water/air temp was not mentioned and is crucial to understanding what happened.
Culpability is always a factor on a commercial trip of course, given that there are certain legal and professional standards that have to be adhered to. But anybody in this game knows the massive complexity and variables that are involved in coordinating responses in fast moving white water. Leadership and training are everything.
Climbing back on to the raft is handy sometimes but not crucial ( an upturned boat is, literally, a slip ‘n slide and can l launch the unsuspecting into a hard object) and it looks like she’d have had very little ability to navigate towards a swimmer were she have been able to do so. It would be pure luck that he drifted up to the upturned boat. Most important is teaching paid passengers (as they’re mostly unable to scramble up onto an upturned boat in any event) to hang on to the upstream side of the boat whenever possible until drifting into an eddy or slack water and how to “swim” correctly in whitewater and how to understand how an eddy can be a safe haven while awaiting rescue by other boats. I’m sure that the basics of simple self rescue were covered in the morning’s safety talk. I like to go over this stuff between rapids repeatedly as, for most, the alien environment generally puts folks into a sort of mental overload which can lead to vapor lock.
But, of course, the odd thing about the guide impressing his passengers with his geological prowess for two minutes while swimmers and flipped boats drift by is of course unfathomable. I’ve never, in 30 years of boating, not seen action stations and whistles blowing etc the moment there’s a “swimmer” in the water. It seems like there’s something fundamentally amiss with a guide doing this - regardless of experience and training. Very strange. At high water a boat/swimmer can go a long way indeed in two minutes.
Boat spacing. Well we all know that even with the best intentions and training spacing goes to hell at various times in a day of boating - most especially at fast high water where the most immediate factor in a rapid is keeping your own line. Ten seconds in fast high water can put the raft ahead of you almost out of sight. The key point then is automatic re-grouping and rallying at the first available eddy below each rapid, and, of course close attention to the boats in front and behind the moment your boat becomes stable and in control.
It’s always so horribly sad to hear of someone going out for a fantastic day of boating, but sadly drowning instead. In all my years of very gnarly boating I’ve never been on a trip with a fatality but have, like all soul boaters, many many times contemplated the misery of dealing with a fatality. My heart goes out to all involved. I’ve always said, however, that there’s no true adventure without risk - the greater the risk, the greater the adventure.
Hopefully all these young guides in this incident understand this, stayed with the sport, and have become even better boaters post accident.

[kimberlynndickens]

Propper prior planning prevents piss poor performance. The 7 Ps. What ever happened to everyone who is participating in the rafting go through all the drills prior to launch? This includes showing you have the ability to save yourself swimming with all your equipment on. A person over board is an EMERGENCY NO MATTER WHAT...

[zacharysmith]

No real mention of what happened to separate Charlie. All of a sudden, he’s dead.

[Guwuber]

1) In terms of the rescue curve, Kathy’s attempt to self-rescue was unsuccessful. Should she have been able to get on top of the flipped raft?
I think that it should be expected of guides to be able to get onto the top of their boat on their own and flip the raft over as just a basic requirement, esp in rivers where flips can happen in dangerous situations.
2) Rescue by other rafters in your group is the next line of defense. Discuss the impact of spacing on the rescue or lack of rescue?
Spacing felt right, just felt wrong that the other boat didn't even try to rescue till it was too late. When I was rafting (an albeit much less dangerous river) our boat stopped halfway through a series of rapids to pickup a kayaker that swam ahead of us but got stuck on a small island. I think that it was important to go in to rescue ASAP.
3) When does rescue mode begin? Should Cliff have waited nearly two minutes in the eddy before pursuing Kathy’s raft?
same as above^

4) If you were the guide in Cliff’s raft, could you make “rescue mode” into an exciting activity for passengers? What would you do?
Again, back to my experiences. When I was rafting and we had to rescue swimmers it always was super exciting and felt really good in the end, so I think that making rescuing other swimmers a top priority would both be fun for the passengers as well as ensure better safety.

[steelemedia]

I ran Westwater in the late spring of 2000. 3, 100 CFS. I was not prepared for big water. I was kayaking and got goofed up in wave trains. I swam each of the first three rapids independently. On the third swim we were two rapids above Skull. The other kayakers got me out of the current. They ran the next rapid and I sat on the river bank, trembling.
A BLM ranger was on a trip with his mom and dog. He stopped for me and put my kayak on the back of his raft.
I rode skull and the rest of the big rapids. He booted me after the drops and I waited for my friends to catch up.

Westwater may is no joke. The water level is everything. The nature of the river changes with the CFS.

I sold my boat a couple years later.

[yada]

I have rafted this stretch of water. And i have been on a raft that flipped in the funnel rocks. And I swam the room of doom until I could get close enough to the rock wall to push myself off and out of the washing machine I was stuck in. And I was pushed off the raft I tried climb into. Some brave canoe-ists rushed out of the eddy to get me when they saw the turd push me with his paddle back into the river ... they broke a wooden oar on a rock in their immediate response to come get me!
They ushered me to a different raft.
I drank a Miller and pondered the bent frame on the boat that threw me.

Good times.

[rivernet]

It would be interesting to know about the duty of the victim. He was probably taught to swim to safety (the raft or to shore, for example). Did he try? Was he advised to do this, or something else?

[timesee]

The guide that trained me on the Pigeon in TN (Ewok) required us to pass before being able to guide. This included swimming the keeper rapid lost guide, as he would kick us out of the raft right before the hole and teaching how to cannonball up if it did keep us. Same rapid he would flip our boat and we had to get on to the raft to flip the raft upright then go rescue all the other trainees that were in the raft. If you couldn't complete this you didn't become a guide. As well as CPR and first aid cert. I thought this was standard protocol. ESPECIALLY on that kind of water!!

[chriscox]

The standards for raft guides are very low. Every commercial trip has guides who are overweight and/or are incapable of climbing on top of an overturned raft. The industry is under regulated.