John Lomas · Prevention of Future Deaths report

On the 3rd July 2012 I commenced an investigation into the death of John Lomas aged 22 years. The investigation concluded at the end of the inquest on 1st October 2015. The conclusion of the inquest was that Private John Lomas died as a result of drowning. The conclusion of the inquest was Misadventure.

The deceased was a serving soldier with 22 Close Support Squadron, 2 Logistics Support Regiment based at Princess Royal Barracks, Gutersloh, Germany. In 2011 he had passed a Joint Services Adventure Training Swim Test in still water but he had recently failed a Military Swim Test and his record had been marked up accordingly. On the 15th July 2012 he was deployed on a one week Adventurous Training Exercise which included white water rafting. Army General Administrative Instruction Volume 1 Chapter 18 states that non swimmers shall not take part in wet activities. A generic risk assessment for white water rafting was completed. Control measures were identified and implemented but did not identify him as a non-swimmer.
At 1400 hours on the 21st June 2012 he was taking part in a white water rafting exercise run by a civilian company on the River Inn at Nesselgarten, Bavaria. The River Inn is dammed by a water company close to the raft launch site. There was no liaison between the rafting company and the water management company. A ‘stowage discharge’ by the water company occurred between 1300 hours and 15.30 hours on the 21st June 2015. The dynamic risk assessment carried out on the river did not identify a change in the river conditions. The raft exceeded the permitted number of persons in white water grade 4+ conditions which prevailed at the time. The boat was launched too close to a stopper and capsized within seconds of being launched. The deceased was pulled from the river at Nesselgarten but was unable to be resuscitated and he was certified dead at 1550 hours.

1. There had been no liaison between Sport Camp Tirol and the Army prior to the white water rafting Trip that took place on the 21st June 2012. No generic risk assessment had been provided to or requested by Sports Camp Tirol as a result there was a lack of understanding as to the suitability of soldiers to undertake the trip.
2. The lead guide and the raft guide did not correctly dynamically risk assess the river Inn on the 21st June 2012 at the point of departure of the trip. They did not recognise that the level of water had risen by one third in the hour preceding the launch resulting in white water of grade 4+.
3. The number of person in the raft exceeded that permitted for the white water grade 4+ conditions that prevailed at the time.
4. The raft on which Private Lomas was a passenger was launched too close to a stopper resulting in it capsizing within seconds of launch.
5. There was no preparatory training on a less challenging river.
6. There was no water confidence test.
7. There was no safety kayak.
8. Although not considered contributory in this particular matter it was noted that the boat had faults which were identified at its last inspection which had not been rectified.
9. There was no obligation to liaise with TIWAG Water Company to ascertain when a significant stowage discharge would take place and TIWAG had no obligation to notify rafting companies downstream who might be affected by the discharge. (The last discharge had been two and half years prior to this incident.)