Background Six firemen drowned during a rescue operation in a low-head dam in Selangor, Malaysia in 2018. If there is good to come out of tragedy, it is in the learning that arises from a careful retrospective look at what caused the incident and any implications for public policy, regulations, and better practices on the ground.

Objective The author was part of a Cabinet-appointed panel to investigate the incident and make recommendations.

Policy Analysis The multidisciplinary panel conducted interviews, studied the incident site, surveyed reports from relevant agencies, conducted a simulation exercise, and reconstructed the events leading to the tragedy. The Minister of Housing and Local Government released the major findings of the Committee to the press.

Policy Implications While the panel understood that the rescuers had to make instantaneous decisions, there were noted areas of improvement that could have been made to reduce the risks taken:

• Unawareness of water-current risks: The firemen were unaware of, and hence unprepared for the ‘whirlpool phenomenon’ in the low-head dam.

• Improve training: Enhancing training for first responders is crucial to handling complex situations.

• Better warnings and education: Public awareness about water-related dangers needs improvement.

• Strengthen drowning surveillance: Implement robust drowning surveillance systems to identify risks.

• Research for prevention: Invest in research for evidence-based interventions for drowning prevention.

• Conclusions

• High drowning risk: Low-head dams are known as ‘drowning machines’ due to their notorious history of causing drowning deaths. The design of such dams should be improved.

• Shared experiences for safety: Professionals from various fields must share both positive and negative experiences to promote safety and prevent avoidable deaths.

• Government support: Governments should encourage the exchange of ideas, experiences, and research to foster safety initiatives and improve water-related regulations and policies.