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I have mentioned before that I read outdoor accident reports and studies in the interest of continuing to appreciate the importance of managing risk.
Bad things happen to good people in the outdoors. Sometimes because they find them selves in extreme conditions that they could not anticipate nor control and sometimes because they failed to apply sound risk management to the situation.
The Sweet Sixteen of BSA Safety is an example of risk management practices that can and should be applied to all of our activities. If these practices are in place our Scouts will be safe and the challenge and rigor of Scouting will be maintained without risking tragedy.
I recently read a report on the Mangatepopo Stream tragedy in New Zealand in 2008 where six students and a teacher died while participating in an outdoor program conducted by The Sir Edmund Hillary Outdoor Pursuit Center. Reading any report of this nature is heartrending. Investigations must lead to findings of fact, including determining who or what was a fault.
The report concludes is that many contributing factors, some organizational, some personal that caused the deaths. Had any one of these factors been mitigated all the deaths may have been prevented. As errors accumulated that tragic day there were many opportunities for intervention yet no one intervened.
A group of nine high school aged students and their teacher were being led through a river gorge by an instructor. Heavy rain (a once in five years amount) swelled water levels in the gorge to flood stage in an hour’s time during the trip. At one point the group was on a narrow ledge about a hundred yards from a dam that was their exit point. Water levels continued to rise and threatened to sweep them off the ledge so the instructor decided that they should continue
The instructor went first and floated around a curve in the river with one of the students. They swam to the river bank and prepared to assist the other students and their teacher by throwing a buoy attached to a rope to them as they came around the curve. Since the rest of the group was out of sight the instructor told them to wait five minutes between each student so there would be adequate time to help them get to the bank around the curve. The instructor was positioned about ten yards above the dam.
The students came around the curve in the river as planned but only five of the twelve survived, six students and their teacher were swept over the dam to their deaths.
The final comment in the report is worth quoting in total:
Young people learn from new experiences. Some of those experiences involve risk. Many outdoor adventures have elements of risk. That does not necessarily mean that it is inappropriate that risks be taken.
Outdoor adventure is an important tool in youth development. Risk taking is developmentally normal, and safety in an outdoor adventure activity can never be guaranteed 100%, but for parents and family serious injury and death are not acceptable for their children that they have nurtured from birth, and whose care they have entrusted to an organization with apparently skilled managers and instructors.
All reasonable steps must be taken to minimize the chances of serious injury. Proper risk identification and risk management is vital to avoid serious injury or death. In the Mangatepopo gorge, this requires an awareness of the environment, identification of hazards, proper assessment of the likelihood of adverse events occurring, and plans prepared if an adverse event occurs. Even if those risk management strategies are in place, complacency can defeat them. Continual awareness is required. For commercial/educational outdoor educational institutions regular emergency exercises are required.
Regrettably, lack of environmental awareness, lack of instructional use of historical information, instructor inexperience, lack of proper assessment before the gorge was entered to ensure there was no significant chance of water levels rising above a safe level during the trip, lack of or inadequate communication when in the gorge between the instructor and the Field Manager or … base staff, failure to implement a crisis plan and dispatch response teams in a timely manner, under-estimation of risks, and complacency contributed to the tragic deaths of Antony McClean, Natasha Aimee Bray, Portia Caitlin McPhail, Huan (Tom) Hsu, Anthony Walter Mulder, Floyd Mariano Fernandes and Tara Rochelle Gregory in the Mangatepopo gorge on 15 April 2008.
The point of writing at length about this is not to find fault but to understand what happened. Once we know and understand what can happen and why it happens we can apply that knowledge to prevent it form happening again.
Clarke,
You have some great songs on the podcast. They also make for some great additions to the slide shows most troops show at their Red and Black dinners!
Thanks for blogging about this event. It was a tragedy and the report makes for distressing reading. However let’s hope that there is not a backlash against such activities and a draconian, reactionary response from the Government.