Jurors in a coroner’s inquest examining an August 2022 rafting death on the Youghiogheny River in Ohiopyle recommended drastic changes Thursday in hopes of preventing future fatalities.

The panel suggested guides be present in every raft on commercial trips and physical modifications be made to Dimple Rock and a second rock nearby.

The six jurors and two alternates deliberated for about an hour after hearing from experts, attorneys, state park staff and employees of one of four outfitters in Ohiopyle over two days.

“All outfitters should act as a team, not as a competitor, and we should have standardized safety measures,” a female juror said.

Fayette County Coroner Dr. Phillip Reilly convened the inquest in the Aug. 13, 2022, death of Julie Ann Moore, 50, of Worthington, Ohio. The jurors were asked to determine if any additional precautions could be recommended for the commercial rafting industry in Ohiopyle.

Moore was among 71 people on 17 rafts taking part in the Lower Yough River excursion organized by White Water Adventurers. The raft she was in with her 13-year-old twin daughters and boyfriend did not carry a guide.

Their raft flipped at Dimple Rock, which is notoriously dangerous, and Moore became trapped underwater a bit farther downriver in the rapids.

Reilly thanked the group for its work. He plans to give the recommendations to Ohiopyle State Park staff and all four outfitters.

“It has in the past always been respected seriously by the park administration,” he said.

The last inquest related to a death in the Dimple Rock rapids was in 2003. Between those recommendations and a study by the Department of Conservation and Natural Resources in the years afterward, safety improvements were made, including the video kiosk and a trail that allows rafters to bypass Dimple Rock rapids on foot.

The findings of that study led the DCNR to conclude altering Dimple Rock physically could increase rafting risks rather than improve the situation.

Park manager Ken Bisbee said, between 1983 and 2003, there were eight drownings in those rapids. Since 2003, Moore’s was the only one.

Senior Deputy Attorney General Scott Bradley told jurors DCNR’s goal is to make the parks as safe as possible.

“I think they take that obligation very seriously, and I think they will listen very closely to any recommendations that you have,” he said.

Jurors mirrored several of the suggestions made by participants in the inquest, including those of two experts who testified Thursday.

Professional kayaker Scott Shipley, a three-time Olympian who owns an engineering firm based in Colorado, said Dimple Rock rapids are “uniquely dangerous” and require rafters and kayakers to make quick maneuvers in a fast current. His firm, S20 Design and Engineering, creates whitewater parks and can evaluate natural resources.

Dimple Rock has an undercut, which means water flows underneath the rock and can be deadly if someone falls into the river and gets stuck, he said. There are other rocks in the rapids that have a similar structure.

Shipley suggested options to improve safety, including moving Dimple Rock or adjusting the riverbank leading up to it to alter the current’s flow.

“One hundred percent, I can make that safer. And that process would involve interaction with the agency and the public,” he said. He added jurors could recommend an independent study of the rapids that would examine how potential changes could affect the river elsewhere.

Charlie Walbridge, a whitewater safety expert, suggested jurors consider requiring all commercial rafts have a guide in the boat.

Guides are along for rafting trips booked through the outfitters, but it is up to the customer to decide if they want a guide in their raft. The outfitters are required to have a specific number of guides based on the number of people on a trip under an agreement with the state Department of Conservation and Natural Resources.

Guides in rafts are focused on their in-boat crew and can give instruction and direction immediately to get paddlers on a safe path through rapids, Walbridge said. It reduces the risk of rafters ending up in the water.

“If it were my company, I would stop doing guide-assisted trips” without a guide in the boat, he said, adding that the clientele has shifted over the years to include women, children and older folks. “I just don’t think it works.”

Walbridge expressed concern about making modifications to the river.

“I worry that it creates an expectation from the user that we have a safe river,” he said.

After her raft — the first through the rapids — flipped, Moore’s then-boyfriend Steven Cole of Columbus, Ohio, said in a recorded statement he was reunited with their boat and, eventually, the twin girls. They watched the rest of their group come through from farther downriver while the girls told guides they saw their mother go underwater and not resurface.

“This is a classic example of what can happen when you have a lot of people on the river — you do lose people,” Walbridge said.

There are safety measures undertaken by outfitters meant to help rafters navigate through the Dimple Rock rapids. They can include guides in rafts, kayakers and a guide standing on Dimple Rock directing rafters with hand signals.

A judge ruled three employees at White Water Adventurers did not have to comply with a subpoena to testify at the inquest. Reilly said he opted to continue with the inquest rather than delay it by appealing the ruling.

An owner and employee of Ohiopyle Trading Post testified about finding Moore and freeing her from the rock.

No one from White Water Adventurers was in the rapids when Joel Means’ group got there, the owner said. While all 11 boats from their excursion made it safely through Dimple Rock rapids, operational river manager Bryan McMullen and other guides learned Moore was missing.

McMullen knew immediately there were three places she could likely be — underneath Dimple Rock, in a spot to the left of the behemoth boulder or wedged on another rock a bit farther downstream. He used a stick to check the two areas at Dimple Rock and found nothing. He made eye contact with his trip’s sweep raft — the last boat to come through — and pointed to the third spot.

“As he floated by, he went by and he saw her,” McMullen said. “We instantly sprang into action. We all three dove into the water. My concern is to get to her.”

They did. And, for 30 to 45 minutes with cold water rushing around them, freed Moore from a rock where her foot was stuck. Guides then were met with difficult terrain along the riverbank and up to the Great Allegheny Passage to get Moore to an ambulance.