The inquiry into the deaths of five members of the Singapore dragon boat team told the tale of an unprepared crew, in a boat they were unfamiliar with, taking on a fast-flowing river they had never rowed on.

But it also threw the spotlight on the practices of an amateur sport that lacked rules and guidelines, and which ran more on team energy than professional decisions.

With no history of mishaps in the water, the question of safety was thrown to the wind: The team never had drills on what to do should their boat capsize or sink.

The nine-member panel chaired by Mr Bernard Tan Kok Kiang did not single out anyone or anything for blame, saying it was not 'within our parameters'.

Its job was to get the facts on what happened on Nov 23 last year in Cambodia, when the national team took part in a race along the Tonle Sap river near Phnom Penh, and make recommendations to ensure such a tragedy does not happen again.

'The biggest tragedy here is not the incident itself but if we had not learnt anything from it,' said Mr Tan.

The panel spoke to more than 30 people, including the 17 rowers who survived and Singapore Dragon Boat Association officials. It also visited the accident site and spoke to the organisers.

The decision to join the race was left until too late, just a month before. The team had insufficient practice and knew next to nothing about the format of the race.

Used to placid water conditions, the Tonle Sap river proved a mighty challenge, with many describing the race conditions as 'the most difficult' they had ever encountered.

The Cambodian boat was also not the flat-bottomed type they were used to. It was shallow and had no rudder. Paddles were also of uneven length.

The panel declined to assign blame to the Cambodians, despite noting the haphazard way in which the event was organised.

Search-and-rescue operations appeared disorganised too, with some survivors apparently believing that everyone was safe.

But rowers Stephen Loh, 31, Reuben Kee, 23, Poh Boon San, 27, Jeremy Goh, 24, and Chee Wei Cheng, 20, perished.

'With the benefit of hindsight, we all have 20/20 vision, but on the day itself, things looked very different. All the nine (Asean) teams were participating. All the nine teams were using the same equipment,' Mr Tan said.

Now the panel wants dragon boat rowers to abide by rules of the International Dragon Boat Federation, which covers all safety aspects.

It also wants the laissez faire culture of the team changed with appointment holders, such as the team manager and captain, responsible for making crucial decisions on safety instead of leaving it to a vote.

At least two instances stood out.

The team departed from the usual practice of arriving earlier for the race because two members were sitting for examinations. They wanted to be together and arrived in Cambodia only on Nov 22, the eve of the race. There was time for only a short practice row.

Then, there was the life-jacket issue: Although some rowers were wary of the race conditions, they did not object to a suggestion that they do without bulky vests, which would have impeded their rowing.

The panel has given the association six months to make changes. Rear-Admiral (Retired) Kwek Siew Jin, who heads the association, said a safety committee was formed last month to review practices.

Asked if anyone should take the blame for poor judgment calls made over the race, he said: 'I find it inappropriate to say if someone should be punished or penalised.'

Madam Lim Ah Moy, Mr Jeremy Goh's mother, thinks the blame should be shared.

'I am puzzled why the Singapore side did not make sure that there were safety measures taken. The Cambodian organisers should be held responsible also.'

juditht@sph.com.sg

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