UKC

If you work in the outdoor industry and instruct, it's worth reading this review of a fatal accident. It may have prompted thoughts of a review of AALA.

http://www.scotcourts.gov.uk/opinions/2010FAI29.html

In reply to Scott_vzr:

Thanks for that. Salutary

In reply to Scott_vzr: An interesting read.

In reply to Scott_vzr:

Thanks for posting... heavy for a sunday night though.

Interesting comments about the catergories of AALA. From their website 'gorge walking' is now included in climbing.

In reply to jezb1:

Certainly interesting, but will new rules and more regulation work againest such long protracted failures to do simple common sense risk assessments. Does it really need an MIA, MIC or Guide to work out that getting youngsters to gorge jump over exposed rocks is a bad idea?

In reply to timjones:
I did wonder that myself. But I guess unless it can be incorperated into another lower level award, although considering the combined level of risks that can be involved in gorge jumping its hard to see which qualification could be used, unless a new one is developed

In reply to timjones:

I've taken two things from this link:
1) if you report a concern make sure you report it in writing and keep a copy.
2) do a common sense risk assesment at the site.

Sadly, and it's probably a reflection of current culture, I thought them in that order.

In reply to Scott_vzr: A lot of my friends were there when that incident happened, she was a lovely girl. Hopefully people and organisations will be able to learn something from it though.

In reply to Rob15: Thats a good thought to have. I only read the thread and the link further because I went to Caldew school at Dalston and had a friend from Wetherall. An awful thing to happen to anyone trusted into your care.

In reply to Scott_vzr: As tragic as that incident must have been for all involved, i wonder how safe it is possible to make what are inherentley dangerous activities and also how safe SHOULD we make these activities?!... reading that review remided me of an article i read in the Times earlier in this year... "David Cameron’s plans mean children will die
And that is a good thing. Young people must confront danger" http://www.timesonline.co.uk/tol/comment/columnists/guest_contributors/arti...

Nobody wants to see anyone die enjoying the outdoors, and certainley not children who are placed under our care, but one element of the challange of these activities is the risk involved, and how much of that risk can we take away without loosing the magic of the experience. I think it is a very fine line, and maybe in this incident it crossed that line and was too dangerous, but hindsights a wonderful thing.

In reply to Sarah Finney:

I agree with a lot of what you say, but in this sad case it appears that a lot of steps and common sense were overlooked by many parties. Foresight could have spotted these risks...

The important thing is what is learnt from it...

In reply to shingsowa: But you could go even further than the review and say Gorge jumping is dangerous before they even get as far as jumping...a child could slip on the rocks and crack there head and die! How far should we go with risk assesments, and when do we stop?! If you took every element of risk out of that day for that group of kids you wouldn't let them leave the building!

It's a sad fact of life that people die, and another fact of life is that teenagers/yound adults want to take risks, this might be in the form of attempting to clear a rocky ledge into a pool, or it could be in the form of them going out and taking illegal drugs, or driving too fast/illegally, but as teenagers they will find a way to take these risks...and some of them tragically will die!

In reply to Sarah Finney:
>>

but this tragic event was not brought about by a group of teenagers doing their own thing, it was part of an organised activity.

In reply to Sarah Finney:

It is also completely fcuking stupid to routinely send kids leaping of the edge of a cliff with protruding rocks below. As was mentioned in the report, the law of averages dictates someone coming as cropper at some point.

In reply to Removed User:

It's such a shame that someone had to die, rather than break an ankle though. A terrible tragedy.

Without visiting the site, it's hard to pass judgement on the activity providers, but it does sound like there were valid concerns raised at ceratin points which weren't acted upon. For me, this is an important lesson/reminder to constantly assess the risks and err on the side of control/caution when leading groups.

In reply to Sarah Finney:

I agree with you Sarah. I wouldn't want a child of mine to do this sort of thing. I have heard of too many fatal accidents from this activity. One of those fatal accidents happened to a friend of mine.

In reply to Scott_vzr:

It seems to me that gorge jumping and gorge walking have strong similarities with coasteering (aka coastal traversing). Neither - correct me if I am wrong - have an NGB overseeing the activity.

However, I'm not convinced that a new qualification or NGB is required. Given that both contain elements of water based activities, climbing and trekking; it isn't too difficult to work out what mix of skills, experience and existing regulation needs to be blended in order to safely lead these activities in specific areas.

The AALA and H&S websites have some limited info on these activities but I think (having just written up a RA for coasteering) that there needs to be more guidance on how to extrapolate and cross-fertilise from one activity to another.

The instructors knew and pointed the rocks out to everybody. Compared to some activities it should've been relatively foolproof, ah but as the law of averages dictates... Telling the children that they would be pushed was the wrong thing to do, wouldn't want to reassure anyone that if they mess it up that they'll be just fine. Seems a pretty good spot for adults as it's not hard to simply say hit those rocks = death.

Should all actvities involving children be totally fool proof or not have any aspect of their safety reliant on their confidence/fitness/skill?

Having read the whole report I really can't quantify how anyone would decide that letting kids jump in a pool from height where they had to clear 1.5m of rocky ground that they couldn't see would be a good idea. Especially as the pool next to it didn't have the associated risk.

Having said that I only walked Crib Goch 4 years ago at the grand old age of 28 having wimped out of doing that route when I was 14 on a school outdoors week. I have bad enough vertigo when I'm off rope myself, as an adult I don't think I could cope with 10 teenagers I was responsible for doing the same, although plenty do. As an adult when climbing I constantly fear the worst and imagine the worst possible scenario. I suppose the main difference between doing a slightly risky scramble and gorge jumping is I can't imagine how the reward would outweigh the risk.

In reply to FreshSlate: in this case its not really making it foolproof. More making a very high risk of severe injury into a much smaller one. Jumping from nearly 10m can still cause injury. However running an organised activity with that level of avoidable danger is plain stupid. which is clearly the view of the report. The point of organised activities like that is to allow percieved risk to untrained people. To trained or experienced people the risk should be very low in reality. What happened here was high risk in reality and that was the result.

In reply to Sarah Finney:

The whole idea of risk assessment is to identify the risks, evaluate the potential consequences and then make a decision. If it's a simple slip or trip on a level surface you might specify that you needed good supervision to prevent horseplay, if a slip could result into a 9.5m fall onto rocks you'd be expected to do one hell of a lot more to mitigate the risk. I'd suggest that however well qualified an instructor or adviser may be no-one should be making the decision that it's OK for other peoples kids to take the sort of risks that this jump involved.

I'm not a fan of our current culture of compensation for everything but if if our child was injured whilst in the care of an organisation whose instructors exposed her to this sort of risk I'd be expecting them to get the chequebook out. Kids will be kids but we should be able to expect better of adults who accept responsibility for other peoples children.

In reply to Graham T:

I completely agree with you. The perceived risk can be as high as you want, as long as the actual risk is managed to an acceptable level.

I take Go Ape as a perfect example, it scares the life out of someone who hasn't learned to rely on a rope and harness, but it's very low risk.

I can't beleive that some of you are actually implying that it is acceptable to expose children to the risk of death!

In the outdoor industry, when children are in the hands of a qualified instructor, then the danger should be reduced to zero - you can still offer them the enjoyment and the thrill of the outdoors whilst reducing the risk of death to zero!

Personally I think that allowing/persuading children to jump 10meters off a cliff edge with exposed rocks at the bottom is in no way a sensible or responsible thing to do and to imply that ''that is what the outdoors is all about'' is just stupid.

In reply to andyandy1:


That's impossible. Anything involving water like canyoning, sailing, kayaking will always have a very slight danger of drowning attached to it, as will anything with heights etc. The idea is to minimise the objective dangers to an acecptable and minimal level.


The reason for my earlier caution in condemning the centre, was that I have not visited the spot in question so I can't make a first hand judgement. It does sound as if this wasn't the ideal spot, but it also doesn't sound ridiculously dangerous if done properly. I do think that it sounds a bit too risky for a group activity with novices though. 9.5 metres is a very long way, and is scary enough off a high board into a pool, so I would like a perfect venue really, but as I wasn't involved I don't feel that I am in a position to comment.

In reply to andyandy1:

It seems in this case that the risks involved were not properly assessed, but it is just not possible to reduce risks to zero. Ideally risks can be mitigated to a point where actual danger is very small, even if the activity feels dangerous to the child.

In reply to Scott_vzr: having just read up to section 12 (point 96) it seems to me that there was a genuine risk to participants, and the poor reporting of concerns regarding the site led to what was an inevitable incident.

This poor girl's untimely death was no accident as it was plainly foreseeable and ultimately preventable had someone implemented a system to adequately record safety concerns.

In reply to New Nick and Monk.

If I was assessing an activity, and found that there was a risk of death, then I would not do that activity unless I could put precautions in place to stop that death from happening. The job of the instructor is to use his knowledge, his tools and his sense to reduce the risk of death to nil. If there is any doubt that there is nothing you can do to stop a death from happening, then it just shouldnt be done.

In reply to andyandy1:

I am not saying that this was a good spot to do this or that things were done as well as they should have been. But I can understand the circumstances that lead to this tragedy, it doesn't sound particularly dangerous if you do things right (how many people had done the jump in the previous 6 years without injury?). I do agree that the possiblity of a serious accident was too high though, and that this spot was not a good place to be taking novices for such a big jump.

On a different point, do you truly and honestly believe that you can reduce the risk of death to zero?

If so, you are a fool.

In reply to andyandy1:

I think The New NickB and Monk were making the point that there is some risk in everything, for example children sometimes get killed in coach crashes, so *any* kind of school trip has to have some risk. There's no way you can reduce that to zero, especially in the outdoors. A child could easily trip over on level ground and kill themselves by hitting their head on a rock, for example.

In reply to Monk:

I would not allow a child to do an activity if I thought that there was any inkling that they were going to die as a result of doing that activity.

If that makes me a fool, then yes I am.

The crux here is the management of risk.

My reading of it is as follows:

1) Several people expressed concerns that the second pool was a risk too far

2) The concerns were not documented so no record existed when management changed. This is clearly foolish, a failure in care and not good practice

3) One manager had failed in his responsbility of assessing risk despite being advised of it and it is no wonder he didn't want to leave Australia

4) The entire risk assessment proceedure was flawed

5) The expert evidnece was IMHO fair. To an adult, conditioned to risk the jump was acceptable, but to a teenager any hesitation would have catasprophic consequences. It is very common for people to hesitate when jumping and most get away with it, but here not so

6) Undertaking activities with some risk is indeed part of the attraction, but not unacceptably so.

7) It is the duty of an instructor to mitigate risk. Canoing comes with risk, albeit minimised and thus acceptable. Heading out into a river in speight in a canoe is unacceptable, ergo, this jump into the second pool was equally ill advised and unacceptable and a risk too far.

All in all, a complete clusterf*ck in management terms and a bloody awful way to die. I could hear the crunch as I read the description.

Sobering stuff.

In reply to John Rushby:
You mention canoeing as an example. this is the only thing I cannot understand in the report. they used the MIC/MIA/BMG qualification as a minimum standard when these activities are more akin to kayaking (fast flowing rivers with plunge pools etc). surely a river qualification is much more appropriate?

In reply to andyandy1:

>
>

Crossing the road, walking downstairs, being in a moving vehicle... I hope to god you don't have kids - they are going to have a very boring life.

In reply to Monk:

I think there is a difference in
'were going to die'
'most likely will die'
'may possibly die'
'there is a small risk of them dieing'
'numerous things would have to go badly wrong for them to die'

In reply to idiotproof (Buxton MC):

I totally agree. But Andyandy1 has repeatedly stated that danger of death should be zero. Personally, I want my kids to have the barest minimun exposure to risk of death, but you can never eliminate it.

In reply to Monk:

sorry was not a direct reply to you but just a point in general..

the first 2 you would probably ask questions of the parents/guardians/instructors. The last 2 is the 'grey area'... I have a friend who would never let there kid do anything like this and even in late junior school insisted on going on all school trips castles, chatsworth, museums etc as a 'helper parent' if not her kids couldn't go. I couldn't understand her position but then I'm not a parent

In reply to Monk:



agreed

In reply to higherclimbingwales:

I thought the same myself.

I think the sub-text is that this falls in between categories, and in part was one reason the accident happened. THing is, the outdoors is so varied you will struggle to legislate for all activites.

Thus the default is common sense, and here, common sense exacerbated by a lack of management and risk assessment experience, failed.

As for the crossing the road analgy. Crossing a road does entail risk, crossing the A65 carries a bit more risk but is acceptable, crossing the M25 is silly for the obvious reasons eventhough a healthy teenager would make it across 99% of the time. It seems the obvious was missed here.

As for the helper parent - that is just daft. A day out at Whipsnade is hardly a game of Russian roulette

And another similar incident.....

http://www.hse.gov.uk/schooltrips/pdf/part-a.pdf

In reply to John Rushby:


an alternative to this analogy would be a teenager is not likely to cross the m25 on their own as they would view it too risky, whereas the "instructor" takes a group to the side of the m25 and says is perfectly ok so long as you run accross at the correct moment.

In reply to andyandy1:

In that case you would never do any outdoor activity because all carry some risk and the goal of the instructor is to minimise these risks as far as possible. I repeat again, it is not possible to reduce the risk of death to nil, but what are we to do, lock everyone up inside and play computer games, surely not.

In reply to MattG:

As usual in these situations it is the test of reasonability.

It is not reasonable to expect any outdoor activity to come with absolutely no risk whatsoever. It is however reasonable to expect that where a potential risk has been identified, that all steps have been taken to minimise it.

Clearly, in this instance those steps broke down and the risk posed made the endeavour unreasonable.

I think there is more than hindsight here, the situation was heading for a messy and inexorable conclusion the moment the first concerns were ignored and failed to be logged.

In reply to John Rushby: I agree, I was more commenting on Andyandy's wrong assumption that anything could be made totally safe, maybe this thread was not the place for that and for that I apologise

In reply to andyandy1: Presumably you would not take a child in a vehicle at all then, or allow them to use any form of public transport as it can be clearly shown that the risk of death is not nil.

I lead DofE groups and have kittens everytime they are let off the leash on expedition. I just have to trust that they will behave in the manner that they have been taught and not take risks they have been instructed to avoid. If I am not happy with their level of competance they receive further training but at some point they have to do it on their own.

The activity being discussed sounds overly risky but to say that you can reduce risk to zero is just plain wrong.

Steve D

In reply to MattG:

No need to apolgise you raised fair points. My reply was more of a general one, just chose to tag it to yours.

In reply to andyandy1:

Clearly it does make you a fool...and it would also mean you fail the child in question, as one day that child will become an adult and will have to encounter real hazards and risks with no adult or instructor to protect them...if they haven't been able to develop dynamic risk assesment skills as a child then they will be extremely vunerable as an adult.

At 18 i was presented with a situation where i was on holiday abroad and i and 2 younger kids decided to go on some trampolines, i could see that they weren't in the best condition but instead of believing my eyes i believed what i had spent the last 18 years being taught...which is that the trampoline must be safe to use, as no adult would charge money for me to go on it, or let me on it at all, if it wasn't actually safe! I very nearly lost my leg! And learnt a valuable lesson...wish i could have learnt that lesson without needing 5 operations!

In reply to Monk and Sarah Finney:

Ok, in your terms, Monk: -

Crossing the road – look both ways, look again then cross when there is no traffic coming,

Walking down the stairs – use the handrail and watch every step,

Child in a car – use seatbelts and car seat, and drive within the remit of the law and common sense.

and in all cases, continuous risk assessment and management.

My point is, (as I’ve already stated in my other posts already) with provision of outdoor activities as a service - assess the activity (which is, I accept, inherently 'risky'), decide if the risk (of death or serious injury) can be eliminated, if it can’t be eliminated then don’t do it. Period.

Are you people honestly saying that you would be happy to take a group out or send a group out knowing that they are going to do something, which, under your instruction, is quite possibly going to kill them!

(i.e telling them to jump off this 30 foot cliff and to try not to hit those rocks at the bottom!)

In reply to Sarah Finney:

erm....I am the fool am I?

In reply to andyandy1: Your roll as an adult is not to simply protect a child until the point that they become an adult themselves, but to teach them the life skills they need to succeed once they become an adult. Teaching them how to cope in specific situations like holding a hand rail, or crossing a road is only part of it, i would guess the intial stage, after that you have to be try to prepare them for any number of unspecific situations they may encounter!

In reply to Sarah Finney:
>

I am not entirely sure what point you are arguing here.

I read it that it cannot be dangerous, as no adult would not allow such a dangerous trampoline to be used. Ergo, no adult, with a duty of care, would allow a young adult to jump from a cliff face if it was dangerous.

In reply to andyandy1:

"Are you people honestly saying that you would be happy to take a group out or send a group out knowing that they are going to do something, which, under your instruction, is quite possibly going to kill them!"

You're twisting (or confusing) other posters words. Nobody on this thread has stated they would do this. You cannot confuse activities where there is a risk of death (i.e. everything we do as part of our daily lives, including climbing and crossing the road) with activities which are (and I quote)"quite possibly going to kill them".

In reply to andyandy1:

So you won't allow your kids to leave the house basically. Which isn't always that safe. More kids died at my school from crossing the road. At least two died in their sleep. Both boys and both really quite fit and sporty boys as well. One in the rugby team and another on the football team. I can't think of any kids that I heard of who died at my school (or indeed any nearby school) on any trip/school activity of any kind.

I think all the outdoor activities I did were quite sane really and well organised, but I still went caving on a school trip (and again at uni) which is fairly dangerous. Went climbing as well once when I was quite young. However taking kids out on climbing/caving/outdoor activities trip/weekend is going to involve a risk of death. Life involves a risk of death. You have to accept that. If you can't you're going to have a lot of nasty surprises.

In reply to andyandy1:
>

You are still wrong. E.g the car - seatbelts and driving safely do not eliminate the risk. They do not stop the person travelling on the wrong side of the road in the dark from completely wiping you out. And none of your examples eliminate human error - it is still possible for you to not see the motorbike when you cross the road or to slip and lose your grip on the handrail.

All you can do is to reduce and manage the risk.

In reply to mattrm:

I think the various arguments are getting a bit conflated.

Some risk is good, makes it fun and challenging and rewarding.

Jumping out over rocks into a pool is f*cking stupid. It is going to go tits up one day, and did and all the warnings went unheeded.

I have done lots of parachute jumps and seen grown men freeze in the door and literally stumble out. No harm done other than a bumpy exit, but as the expert witness said here - the same at the 2nd pool would have tragic consequences, for what is natural and common human behaviour.

In reply to jamie84 and Sarah Finney:

I dont think you have fully read my posts Jamie, or the posts of those who disagree with me:-

My original point was that I don't agree with some of the people here implying that it is ok to expose groups of children to a risk of death!

There were then replies from Monk and Sarah and New Mike, basically saying that it is ok to expose children to a risk of death and that it is not possible to to eliminate the risk of death! (otherwise they will be bored, eh Monk).

My original point was that it is possible to have yor group enjoying the outdoors and its activities whithout the risk of death!

Some people here, Jamie, have implied and stated that it is not possible to do outdoor activities and to teach young people life skills(Sarah) without exposing them to the risk of death!! (or dodgy trampolines).

I hope to god that none of you are outdoor instructors.

In reply to andyandy1:
Fair enough, I think I understand where you're coming from (though I don't agree). From my take on it, it's all about acceptable risk. I would expect the risk of death to be very small for most group outdoor activities led by an instructor (but there would still be a risk of it).

In reply to higherclimbingwales and others:

IMHO
Zero risk is unachievable
Any risk is unacceptable
A carefully assessed risk, appropriately managed and reviewed can be acceptable

In reply to Scott_vzr:
This is a truly tragic case and on reading the report my thoughts were with all those effected, the friends and family of Laura particularly as they have suffered a terrible loss.
I feel for the instructors too, who may have made a misjudgement over safety, but meant no harm what-so-ever and have to live with the greivous consequences of their mistake.
It seems harsh to comment on the rights and wrongs and I'm sure lessons have been learnt, anyone on here who does have a role of responsibility with young people outside will surely have stopped to think.
Looking at the cold facts it appears that an unacceptable risk was taken in this instance, but young people should not be denied the pleasures and challenges of outdoor activities that have potential risks attached altogether. Risks need to be managed carefully and risk assessment needs to be a dynamic process in the field, not just a form filling exercise.
I sometimes fear the mass of paper risk assessment done these days leads to a "we've ticked the risk assessment box" attitude that allows complacency to set in just when the really important dynamic risk assessment process should be taking place.

In reply to The Ivanator:


I agree, both are essential IMO, the initial paper assessment is very useful as there are things that may not be immediately apparent when you are out on the hill say.
Dynamic risk assessments are essential though, as you can never predict what may happen. I think this part is much harder to attain as it comes from experience combined with training.

As I said previously, the key to all of this is apparent risk, you can give the impression of something being dangerous while it is actually pretty safe, this is what gets people coming back to do it again.

In reply to Scott_vzr: As a parent with a son who enjoys adventure activities, the replies on this thread have raised considerable concerns. As has been said previously in this instance it seems that a serious accident was inevitable at the second pool. Not only is this unacceptable but it actually teaches the children involved the opposite of what some are claiming. If they are teaching them about acceptable risk surely they should have showed them the second pool and discussed why it was too dangerous compared to the first pool. The next time these children tried this activity they may be alone and unsupervised. You don't want them thinking its okay to pick a spot above jagged rocks!
I'm sure lessons have been learned by the people involved in this tragedy but I am worried about the way some on this thread seem to be underplaying the concerns for the saftey of others children. As was stated upthread an activity for children should be exciting, but in reality very low (ok we know 0 is impossible)risk. I don't expect any instructor to be taking any risks with my child. Yes I am an over protective parent. That is my decision and I expect any person employed in care of my child to be the same.

In reply to AlasdairM: I couldn't believe my experience of Go Ape - twenty minutes of instruction/observation then off you go 10 metres above the ground - I'd like to see the risk assessment for that.

pmc

But you are over 18 ? So exempt from AALA licensing.

In reply to andyandy1:

You seem to be completely missing the point that it is impossible to reduce the risk of death to NIL!

It can be mitigated to a negligable amount but it never ever will be nil.

The point of this discussion has been and should be about the fact that the risks were not addressed adequately and the result was an unacceptably high risk of death.

I really suggest you get a grip on reality or shut up.

You are not contributing anything useful or constructive to this discussion.

In reply to baron:

The training is more than adequate.

In fact in my experience,(in the last week) the training was excellent.

Clear, concise and repeating the message/mantra.

It is a simple straight forward system with, in many situations, more redundancy than required.

And at the end of the day it's for adults over the age of 18 to decide if they want to take the clearly pointed out risks of death, or not.

You are offered a full refund if you bottle it after training.

What is the issue with that.

In reply to Ghastly Rubberfeet:

I'm afraid it yourself that is completely missing the point. If you don't understand what Andy is getting at read his posts less literally. He makes a lot of sense.

In reply to Scott_vzr:
IMO, The risk assessment DID NOT fail to identify the risk, as was stated in the report.

Quote “The risk of striking a rock on descent was categorised as having a low probability and a medium to high severity.”

As can be seen the risk was evident, it was the probability that was wrong and it should have been HIGH. Or should it?

The actual evidence was that many people over a long period had jumped this particular pool without incident, this was the first serious problem. This to me indicates that the risk rated as LOW PROBABILTY was probably correct.

It is a sad fact, but any risk rated with low probability will happen to someone at some time and the consequences could be serious. Therefore, it would seem either a high or low probability is not even worth recording on the risk assessment,

In reply to Removed User:

Reading his posts less litterally leads to only one conclusion.

That risk must be mittigated to an acceptable level.

I believe that is what I just said.

Whereas Andyandy1 is quite clearly stating he wants the risk at 0.

What is difficult to understand?

Does he mean 0 or does he mean nearly 0?

Perhaps I am being thick.

If there is another interpretation, perhaps you would be kind enough to explain it to me.

In reply to Ghastly Rubberfeet:
>
What do you consider to be acceptable? If you don't define that your statement is of little value.

I interpret Andy's posts to mean that he expects that the risk should be negligible to all intents and purposes. I think that's entirely reasonable and achievable in many activities.

In reply to Monk:

I've only read down as far as this post so far, after reading through the entire report yesterday - but, YOU don't have to have visited the spot - the inquiry did, read through the whole thing - including the testimony of the various experts - they went to inpect the spot, they made very accurate measurements including the velocity the person jumping would need to clear the rocks from a standing jump. They concluded that, based on all the given evidence, "if done properly" was not a reasonable assumption to make of children supervised on such a jump, in spite of instructions about the direction of jump and how far to step out.

In reply to ClwydTraveller:


I would have thought that an acceptable probability of a fatal accident occurring would be something like 10 million to one. No more than a few thousand of these jumps would have occurred before this tragic accident occurred so I'd suggest that the risk of a fatal accident occurring was at best 10 thousand to one. That is not a low probability.

Anyway from the report: "The distance from the point where Laura jumped is 9.5 metres vertically above the rocks where she landed. The rocks where she landed continue out into the pool for a distance of 1.5 metres from a point directly below the jumping point."

Does that sound safe to you? The problem is that if the jumper makes a mistake it is not a fail safe situation but a potentially fatal one. What were they thinking of.

By the way, if you're about to tell me that I wasn't there and don't know what I'm talking about, I've walked/climbed that burn in winter all the way from the car park to the Loch and I'm amazed that anyone would consider allowing children with little or no prior experience make a jump of that height into any of the pools.

In reply to Removed User:

And there are numerous other interpretations of his posts, each one of them equally valid to the intrpreter!

What I am saying is exactly what you are saying, but it isn't zero, which is my interpretation of what he is saying

Of course all reasonable steps should be taken to eliminate risk.
Why would you want to do anything else.

Implying zero risk is not a good idea because things can and do go wrong.

I'm not going to sit here all night dreaming up numerous unlikely, improbable, but entirely possible circumstances to illustrate my point.

Perhaps, if he really meant "nearly zero" he should have said that in the first place.

In reply to Ghastly Rubberfeet:
No you are obviously not, but perhaps someone with similar type of views to AndyAndy1, that thinks risks should be mitigated 100% wrote the report is when it becomes ridiculous. However, that’s not too bad on its own, but when these views are used to blame others in what otherwise is a very well run company, it is not good. The company have after all complied with all the requests in quite some detail.

Perhaps the BMC participation statement needs to be stated to help.

The BMC recognises that climbing and mountaineering are activities with a danger of personal injury or death. Participants in these activities should be aware of and accept these risks and be responsible for their own actions.

In reply to Removed User:

I am sure Andy does mean that, it is a shame that what he describes does not actually say that and so adds nothing to the discussion. The issue is about acceptable levels of risk and clearly for minors being instructed the acceptable levels very low.

In reply to ClwydTraveller:

It may be well run, but in this instance the management broke down, the report fairly and clearly says so.

Also, the BMC statement is aimed at adults and in this case we are talking about children, led by instructors who are to an extent acting loco parentis.

I do not think risk should be mitigated 100%, but I do think that when engaging in something such as this, the system should work. Two instructors raised concerns, they were not acted upon nor recorded. That is a failing. The jump itself was questionable and had no fail safe. Hesitation is not unexpected and it was only a matter of time.

There shouldn't be a witch hunt, just taking a step back and looking at what happened and why. If someone in a senior postiion had followed through concerns raised and gone out there and seen the site they might well have banned the very activity the management claimed they had no idea was going on......

In reply to Sarah Finney:

Totally agree...

From the age of 14 I was regularly going off kayaking with friends who where the same age or a few years older than me (but still classed as children in the eyes of the law). Kayaking on grade 2/3/4 water and running rapids and waterfalls, swimming in rivers and in waves, rescueing each other/boats/paddles etc.

I had been taught early in my paddling life to assess risk, and was guided and encouraged to make my own decisions, without just being told what to do. It enabled me to develop the ability to risk assess situations and dynamically risk assess too. I knew there was a risk I/my friends could be pinned against a rock in our boats, get a foot entrapment, get stuck in a tree, get stuck in a weir with a big towback, run a bad line down a waterfall and break ourselves, develop hypothermia after a cold swim/on a cold day, drown...the list goes on....
But we knew how to reduce the risk. We of course still had the occaisional epic! - and learnt from our mistakes. But I/we were able to put my/our training into practice when incidents arose. My parents trusted that at 14 or so I was able to do this and I respect them alot for trusting myself and my friends. I certainly trusted my friends with my life.

This experience in my teens helped me so much when I started instructing...


On a separate note. I've worked in several centres in England and Wales and they asked for:
ML
with a BCU white water qualification (White water safety and rescue/ WW kayak/Canoe) OR a Caving qually.
Some required SPA if ropework was involved.
I've also worked places that asked for these only as training courses and would give a site specific (qualification).

>In reply to Eric9Points:
>I would have thought that an acceptable probability of a fatal accident occurring would be something like 10 million to one. No more than a few thousand of these jumps would have occurred before this tragic accident occurred so I'd suggest that the risk of a fatal accident occurring was at best 10 thousand to one. That is not a low probability.


What the acceptable risk is whatever it is deemed to be by the person sanctioning said activity, be it the client, the instructor, the CI, the governing body or the coroner.

As an example according to the Department for Transport 2807 children were killed or seriously injured on Britain's roads in 2008. According to wiki in 2008 there were 11million children in the UK so that makes it about a 3900 to 1 chance of a serious injury or death to a child in the UK on the road. By the very nature that cars/vehicles have not been banned we (as in society) obviously deem this to be an acceptable price for the enjoyment/convenience of motor vehicles.

I only mention this to point out that the risk of a serious accident is not negligible in even the most routine day to day tasks so expect the risks to be "something like 10 million to one" when walking in the mountains, climbing a crag or paddling a river is very naive.

I would agree though that from the description of the 2nd pool location in the gorge incident it does sound unsuitable for a novice group to be using, and wouldn't be one that I'd choose to use at work.

In reply to Mr.Ric:


Well, in fact any child would be on or in the vicinity of a road many times a year, let's say 1000 times a year. So the probablity of an accident happening to a child when they go onto a road is perhaps 3.9 million to one. The probablity of a death occurring on that jump was perhaps 10 thousand to one versus the 3.9 million to one. Conversely if one person did that jump 1000 times in one year then the probability of death is 10 to one.

However I find talking about life and death in numbers rather distasteful and some common sense would tell one that crossing the road does not equate with this activity on many different levels.

In reply to Eric9Points: When concerned with the end result looking at the exposure time for each area doesn't really make sense. If a child dies at during the year a child dies. Just by turning that around you could say that in the time taken to reach adulthood there's a 216 to 1 chance of serious injury/death on the road. When you start twisting the statistics you can make them show anything you want.

While your common sense might tell you one thing, my experience tells me another. As someone who regularly takes children out on activities and has spent many many hours training and performing my own risk assessments of said activities I know that the most dangerous part of any day is the bus drive to the location. For one thing it's the only point at which there's a real possibility of 16 children being killed on session.

Don't get me wrong, I'm not trying to defend the decisions of the instructors involved (or condemn them), or make light of the real risks that we're exposed to during said activities. Just that they need to be put into context and that some risk is acceptable as a price for all the benefits and learnings the experience provides.

Or perhaps to put it a little more succinctly from the health and safety executive themselves; "Our approach is to seek a balance between the unachievable aim of absolute safety and the kind of poor management of risks that damages lives and the economy. In a nutshell: risk management, not risk elimination".

In reply to Removed User:

Why compare with an incident which did not meet the minimum standards that we all expect.

In reply to Mr.Ric:
As someone who regularly takes children out on activities and has spent many many hours training and performing my own risk assessments of said activities I know that the most dangerous part of any day is the bus drive to the location. For one thing it's the only point at which there's a real possibility of 16 children being killed on session.

but on reading the report you couldn't say the same about this tragedy.

In reply to andyandy1:
>

>

Afraid so, in a voluntary capacity. I wouldn't have achieved my qualifications if I had blindly stated that the risks were zero during my assessments. You have to acknowledge the risks and do everything in your power to reduce them to an acceptable level. Obviously, an acceptable level is a very very low level of risk, but you can never entirely eliminate the chances of a freak accident. Any activity in the water will always have a very tiny risk of drowning (even at an indoor pool). Otherwise, why would we bother having first aid qualifications if there was no risk of needing them?

In reply to Hannah m:

I think you have misinterpreted what I was saying. I was simply meaning that I am in no position to add condemnation on the activity centre and have no desire to. The proper channels have conducted a detailed inquiry. I have repeatedly said that I don't think that this particualr jump was a good idea with a group of novices. What I meant by "done properly" was a group of consenting and experienced adults. To be honest, it sound pretty scary to me, but I'm nervous going off a 10m board into a pool.

In reply to John Rushby:

It is not as clear to me as it appears to you, that the management did completely break down. The Sheriff had to rely on expert opinions and recollections. There is an example in the report where information that did not support the expected outcome or was not presented in an articulate manner was dismissed as “evasive” but was crucially not seen as “lying”.


The BMC statement is NOT just aimed at Adults. The BMC has a clear under 18 policy. FYI the BMC youth participation statement is reproduced.

"Parents and young participants should be aware that climbing, hill walking and mountaineering are activities with a danger of personal injury or death. Parents and participants in these activities should be aware of and accept these risks and be responsible for their own actions and involvement."

Further information can be downloaded free.
http://www.thebmc.co.uk/Download.aspx?id=9


I would suspect that a better method of feedback could be introduced. However if all concerns of everyone were acted on and recorded no one would do anything else. They can only be categorised as failings with hindsight when the relevant concerns turn out to be true. Some people correctly identify lottery numbers, but not many find out they are subsequently right.

That is why the risk assessment was completed. Risk can not be completely eliminated otherwise it is not a risk.

Yes, this applies to any risk. Irrespective of the probability rating on the risk assessment, it will happen, at some time.


But there was.
Heads rolled, the company was fined and there will be implications for the whole industry.

In reply to Jim Hamilton: >
but on reading the report you couldn't say the same about this tragedy.

Based on the description of the jump and the type of group taking part I would agree, I should of elaborated that it was any of the days out that I run.

Although that's not to say having activities with 'must make moves' isn't to be ruled out, just that they can be managed a bit better then it sounds happened here.

In reply to Mr.Ric:

as a matter of interest what other activities with kids involve "must make moves" , and how could this gorge jumping activity be "managed" better ?

In reply to Jim Hamilton: Well I haven't seen the jump so it's purely speculation, but whilst a jump that necessitated a large step out in a particular direction over an unseen hazard almost certainly isn't going suitable for regular use by children it might well be suitable for use on a military resettlement course for example.

There are many many times on an activity like scrambling where a fall has the potential to result in death. You don't have to fall from very high to have a serious injury and when scrambling up the side of a mountain/traversing around a cliff route there is always that potential. The only way to rule out the risk is by just not being there in the first place. Personally I think banning children from these kind of activities would cause far more damage in the long run as opposed to the very small number of times things go seriously wrong in the outdoor industry.

In reply to ClwydTraveller:
>>>>>>>>>For a Sheriff (or Judge) to minute that someone was being evasive is quite damning. To minute they were lying has altogether differant conseuences. The subtext in legal decisions can be quite "entertaining"

>>>>>>>> I am all for putting kids into adventurous challenging situations, hell I surprise myself that I survived my own childhood. But I go back to the same point again, the leap ove rth rocks was too risky. It was only a matter of time before someone refused at the fence and it them.

Good. The system failed and it should be used as a lesson to the industry.

In reply to John Rushby: the report to me concludes that this particular outdoor centre was run by idiots and chancers and as a result some poor girl lost her life.

However, one thing concerns me and that is the expectation of society that adventurous sports should be managed and the risk mitigated, in other words ensure that the idiots and chancers arses are covered. Society should be aware that the risk is real and accidents do happen and no amount of input from the HSE will stop this. The real issue lies with the incompetence of humans and the selection process for hiring the idiots and chancers.

I tell you what though, I used to do far more extreme activites as a kid, probably just as well my parents never knew, at least there wouldnt have been anyone to blame if I had come a cropper.

In reply to Erik B:

I know individual instructors have to have read and understood the risk assessment (which in this case was inadequate) and be able to dynamically risk assesss (on session) but if management agrees with a certain activity which they blatently do despite saying they had no knowledge of it being undertaken then the issues lie higher than individual instructor level.

The instructors where shown to have done everything right in regards to their response to the situation - having good group control, keeping the group safe, seeking help, giving swift and appropriate first aid without creating more casualties. IMHO it's not individual instructors at fault but the systems of a centre in regards to their control and assessment of activities. I know of centres who have used similar jumps in the past but dropped them from activities many years ago after 'modern' risk assessments.


But in this situation the instructors and centre act in loco - parentis. They are responsible for the child.

In reply to Katie86:

Modern risk assessments - i.e a review of the risk assesments found that the jump was too greater risk. The original risk assessments had been done many moons ago when there wasn't such a greater emphasis on risk assessment.

In reply to Anonymous: I don't believe anyone is suggesting that the probable/almost certain outcome from failure to make a complicated move being death is acceptable for a group activity involving children just pointing out that it's often a possibility of such a result. However it can often be deemed acceptable to have a likely outcome of failure being death/critical injury if the probability of failure is low.

When considering such activities what I look at is what is the likely outcome from this going wrong and then looking at how likely it is to go wrong and what if anything can be done to reduce these likehoods/the effect this would have on the session.

For example on Saturday I took a group coastal traversing, during the walk there is a small gap (roughly 70cm across) which you must step over. If you were to fall down the gap it's about a 4m drop to a rock surface. Now when considering this route I felt that if someone were to get the step across wrong and they fell it would likely result in a very serious injury with a possibility of death. However due to the ease of the step across and the fact that the hazard was clear and obvious I deemed it unlikely that anyone should fall, so it was a reasonable risk to take for the activity. Control measures were; pointing out the gap to the group, standing next to the gap in order to assist if necessary.

Also it's worth noting that when the risk is obvious it doesn't have to be pointed out by an instructor to have considered it being accepted by those taking part/parents of those taking part. If someone climbs 3m up and then falls breaking their back they can't reasonable claim that they were unaware that it's possible to fall off/that you can get hurt falling from that height.

In reply to Anonymous: I agree

Kate, when I referred to idiots and chancers I wasnt just talking about the instructors mentioned in the report

In reply to Katie86:

The process was formalised in (I think) 1992 and hasn't changed since. There is a fallacy widespread in the UK that, if you carry out a risk assessment, then in some way you are 'off the hook' if there is an incident. This is wrong headed, risk assessment is a tool to try and impose some objectivity on what is quite a subjective process, the person making the assessment needs to competent (If they're not then their employer may be liable). If a hitherto competent person carries out a risk assessment that is clearly wrong, then they may be personally liable and certainly their employer is likely to be liable for the consequences of an incident.

In reply to Erik B:

Aye but Erik, why didn't an instructor look at the thirty foot drop with a rock ledge at the bottom as say to themselves "phuq this, this is stupid". All this pish about ticking boxes and management systems obscures the fact that common sense went out of the window. Blaming your managers is an abdication of responsibility.

Hope things are fine in Helsinki by the way.

In reply to Removed User: indeed, but its a heady mix when you have a halfwit instructor and a manager who either 1. employed said halfwit and/or 2. choses to ignore whats going on in his domain of responsibility

I read the whole report and the centre was clearly a complete and utter disaster structurally from the top downwards.

In reply to Removed User: PS things are going well here in Helsinki, its very civilised but not really my cup of tea, soulless could be the word Im looking for..

In reply to baron: I have taken groups of kids to go ape, there is a full and comprehensive risk assessment available, and all under 16s had to be supervised directly at all times by a participating responsible adult.