Rule 5 / Case 1

Plan For The Worst That Can Happen


Todd Ellison, October 7th, 2011 Lake Mille Lacs, Minnesota


Todd Ellison

Note No big blunders were made in this incident, and paddlers should take that as a cautionary note. Oftentimes, a combination of small errors is more than enough to cause trouble.

- Moulton Avery

Todd Ellison, a very strong, skilled paddler, went out with four friends for what they thought was going to be a great 16 mile (26 km) downwind run on surf skis. Waves on Lake Mille Lacs were 4-6 feet, generated by 20–30 mph (32–48 kph) winds. The air temperature was 77F (25C) but the water temperature was 60F (15C). For protection, Ellison was wearing a 3 mm Farmer John wetsuit and two rashguards. ​ Ellison had less experience paddling a ski in those conditions than the other paddlers. As a result, he was getting pushed slightly off course and wasn’t moving as fast as the other paddlers wanted to go, so they split the group - an action they had discussed prior to launching. Three paddlers went ahead, and one of the strongest paddlers stayed behind with Ellison. Although the group as a whole had 3 VHF radios and 4 cell phones, the only communication device that Ellison and his companion had was Ellison’s cell phone, which was in a storage compartment on his ski. ​ When Ellison capsized 2.5 miles (4 km) from shore in rougher, shoal water, the Velcro portion of the ankle leash that was tethering him to his ski failed, and his boat blew away, taking their only means of communication – his cell phone – with it. ​ Attempts at towing or carrying him on the other ski failed so, by mutual agreement, his companion took off on a desperate 45 minute race to shore, in breaking beam seas, to get help. The search was commenced shortly afterwards, around 4:00 pm, three hours before sunset. It was too windy for a helicopter, so a fixed-wing aircraft was used to fly a search pattern augmented by multiple boats on the water. ​ They searched until 9:00 pm (5 hours) in the general area of the capsize without finding him. When the search resumed the following morning, he was found floating dead in the water about a mile from where he had capsized the previous afternoon. ​





Worst Case Situation One of the worst calamities that can befall a cold water paddler is to loose his or her boat. This can happen because it blows away, it sinks, or the paddler is unable to reenter it. This particular tragedy was set in motion by the failure of Todd Ellison’s ankle tether, which resulted in the loss of his surf ski. The Criticality of Tethers A boat tether can be a critical piece of safety equipment, particularly in windy conditions. Most board surfers consider them standard equipment and it appears that most surfski paddlers do as well. For some inexplicable reason, sea kayakers rarely use them, although losing a sea kayak is every bit as hazardous as losing a ski. All of the paddlers on this outing used ankle tethers, and it’s very easy to understand why losing a boat wasn’t at the top of their mental list of things that could possibly go wrong.

At the time of the accident, assisted surfski rescues were rarely practiced. Furthermore, few skis have deck lines or a place where a tow rope can be attached, and few, if any, surfskiers wear tow rigs. The fact that ankle tethers are standard equipment and the surfski capsize recovery drill is to hop back on the ski may have led to complacency within the entire sport - a situation compounded by the fact that ankle tethers seldom fail. In risk analysis, this kind of low probability / high impact failure is often referred to as a Black Swan event. It's rare, but when it happens the consequences can be extreme. Under the circumstances, the failure of Ellison's ankle tether was catastrophic, and there was no way to fix the problem. Even if his companion had sprinted after Ellison’s boat the instant it was lost, it’s questionable whether he could have caught it, and if he had, what then? There was no way to secure it and bring it back, to say nothing of the very real problem of retracing his course and finding Ellison, who was obscured by waves and floating alone in very rough conditions. Reasonable Safety Precautions The air temperature was a warm 77F and the water temperature was 60F – cold, but by no means extreme. Given the fact that the American Canoe Association promotes 60F as the temperature below which a paddler should “always wear a wetsuit or drysuit”, it’s readily understandable how an experienced paddler like Ellison could feel he was being sufficiently cautious for the conditions. He wore a PFD and a wetsuit, he was tethered to his ski, he was paddling with an experienced group, and he brought his cell phone with him. That's a lot more precautions than most open-water kayakers take. Not Enough Protection Thermal protection isn’t a magic charm. What it does is prevent cold shock and delay incapacitation. In other words, it buys you time. The issue is whether your gear buys you enough time to either fix your own problem or to be rescued. See our article: How long before I'm rescued?


Although his 3mm neoprene wetsuit was fine for multiple spills and reentries in 60F water, it wasn’t nearly enough to protect Ellison during a prolonged immersion lasting many hours, let alone overnight. The farmer john wetsuit design also left his arms exposed.

In his choice of thermal protection, Ellison certainly wasn’t outside the norm, because 3mm is a very popular wetsuit thickness. Many paddlers unwisely wear it on water considerably colder than 60F. However, unless you happen to be fat, it’s simply not enough protection for an immersion that lasts hours. The issue - particularly in rough water - is not hypothermia, but rather physical incapacitation and subsequent drowning. Regardless of what you wear for protection, it’s wise to spend time floating around in the water to see how long it takes you to get cold. Not until you become incapacitated but simply until you feel cold - just so you can see for yourself how warm your protection will keep you at that particular water temperature. Most paddlers underestimate how much protection they need, and this particular field-test injects reality into the system. A Seemingly Insignificant Mistake As it turned out, splitting the group was certainly problematic, but they had discussed the possibility in advance and were all in agreement when the decision was made. Under the circumstances, the critical issue was having all 3 VHF radios and all the cell phones except Ellison’s depart with Group 1.


This is the kind of seemingly insignificant mistake that’s very, very easy to make out on the water – even for experienced paddlers. Had Ellison not lost his boat, it would doubtless have passed unnoticed. Once the boat was lost, however, cold water, the inability to let the other group know about the crisis, and the inability to quickly summon help combined to set the stage for disaster. (Click to zoom image)


Communications gear like cell phones, personal locator beacons, and VHF radios should be attached to the user's PFD (lifejacket) rather than stowed in a hatch.


Finding The Victim Regardless of whether your vantage point is a boat or an aircraft, it is exceptionally difficult to spot a single, boatless paddler in the water, particularly when conditions are rough. (See photo below)


A strobe light, a bright rescue streamer unfurled in the water, flares, a signal mirror, and waving a paddle in the air all increase visibility. Had a rescue strobe light been attached to Ellison’s PFD, it would definitely have helped rescuers find him after sunset. Whether he could have survived that long without drowning is unknown.

Spotting A Victim - No Easy Task




















Major Contributing Factors


  • Unable To Recover From Capsize

  • Unable to Call For Help

  • No Light - Invisible At Night