# Problem Solving Community Accident Reporting



## glenn (May 13, 2009)

Charlie Walbridge has done an excellent job doing exactly what you are talking about with the AW accident reports. I own several years worth of accident reports in paperback print format, and read through them from time to time to keep myself sober about risk but also as a reminder most accidents are oversights in basic on river protocol. A major drawback to the AW accident reports is the timing. They only happen once a year while accidents/interest and risk taking happen over the course of the year.

To me the buzz is a separate issue where a discussion is the goal. I'm much more interested in hearing from seasoned paddlers how to better approach the same problems groups faced during events that I myself may be at risk for. That is different than providing the basic facts and a cursory look at the primary and secondary factors in an accident. Doing so tactfully is personal responsibility and you aren't going to make everyone happy.


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## The Kooz (Sep 22, 2013)

As someone who unintentionally stepped into the hornets nest of the previous thread, i think this is a great idea. maybe AW could have the forms available on their website, and they could assemble impartial review teams? I'm not sure the buzz would be the proper location, since...you know... it's the buzz. Then again, we have moderators, why not incident reviewers?

if that debacle of a thread proved anything, it's that root cause analysis and victims/survivors need to be seperated.


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## glenn (May 13, 2009)

Again AW already has the process in place. The process from my understanding does not require all involved to give an interview. It simply requires one person who has a rough idea what happened to speak up. In many cases the report that makes it into the AW report is several steps into "whisper down the alley" as they fill in the report based on a news publications report. I think they do the best they can given limited time resources and people willing to step forward with information.


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## yojimbo (Oct 12, 2003)

I agree that this is not the forum for a formal, 'reviewed' accident analysis. Walbridge at AW does an admirable job of making an annual compendium from various 'official' and unofficial sources. Maybe AW can add a forum to make it easier to publicly collect and comment on these reports.

That kind of formalism aside, I believe Mountainbuzz does provide a good local forum for this kind of information/story/reporting to happen. I've seen many accident/bad situation tales here which were very informative (search for the Bear Claw knife story, etc). Yes there is a moderate background noise component but it's pretty easy to identify and filter. It's a forum. I do not see the need to require any posting to take into account every participant's point of view.

The American Alpine Club publishes an expensive annual book, "Accidents in North American Mounatineering." While it's a good read and reminds me of all the dumb things I have ever done, the back and forth of an informal forum can provide lots more points of view and food for thought on a more timely basis.


IMO

Jim


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## deepsouthpaddler (Apr 14, 2004)

My two cents...

AW does a good job compiling reports from paddlers, but that info is sometimes minimal and barely scrathes the surface of what really happened and why. 

I think where the paddling community has problems is that few folks understand accident / safety science and they let emotion trump effective investigation/ reporting. Accident investigation and reporting is a mature field in engineering, medicine, and industry and possibly other sports, but people not educated in this miss some key points. Accidents typically have the same form or structure whether its a plant exploding, a train derailing, a guy falling off a ladder hanging christmas lights or a paddler dying on the river. Many see an accident as a random stroke of luck with no cause. Accident science states that accidents are not random dumb luck but the combination of one or more factors that yields an accident. In hindsight almost ALL accidents are preventable. 

Couple issues that I see...

Timing: Many folks take the emotional response of "its too soon", or "not now". I have yet to see one of these folks give an answer to when is a good time, but any time from a day to a week to a month or more have all been called too soon. Accident science states that investigations should be done as soon as possible because memories are fallible and motivation to follow through wanes over time. 

Root causes: every accident has one or more root causes or contributing factors. Emotional folks get puckered because they see this as malicious blame. No one goes to the river planning to die, and when someone does die something went terribly wrong. A missed line, bad gear, lack of skill, alcohol, poor group safety, cold water, high / low water, poor planning, physical conditioning and health etc are all common contributing factors. As a community we are quick to point out when a drysuit or a good rope throw saves a life, but we would typically struggle to assign root causes when a fatality is involved. 

Why? One tool accident science uses is the 5 why technique. You basically keep on asking why until you get to the fundamental reason(s) why. For example a paddler might drown in a swim out of a hole...Q: Why did they swim? A: bad line. Why did they have a bad line? They didn't scout. Why didn't they scout? It was getting dark. Why were they running out of daylight? Unplanned boat repairs. In this example poor line, lack of scouting, running out of time, and unplanned issues all contributed to a cascade of events that resulted in the accident. Some call this the swiss cheese effect... Where multiple gaps line up and multiple safety layers are all breached an accident can happen. Any one individually might not cause an accident but in concert they can. Each safety precaution is like a piece of swiss cheese... Effective when its solid with a gap where there is a hole. When you lay multiple pieces of swiss cheese you almost never have the holes all line up. When the holes line up, all your safety systems have failed simultaneously and thats when bad things happen. This logic applies to events like the space shuttle disaster, the Fukushima nuclear disaster, accidents on everest, and deaths in whitewater. The main takeaway here is thats its all too easy to stop at... It blew up. Not going all the way to why prevents the true understanding of what happened thus preventing others from learning and avoiding the same mistakes. 

There is nothing new to learn... This is a huge mistake. There is typically always something to learn from an event, and many key issues are learned by analyzing trends in large data sets over time. Just because you cant think of something new to learn doesn't mean that something cant be learned, or that this accident might yield more information when put into a trend. 

Exposure. One of the benefits of good accident reporting is maintaining high awareness and vigilance. Even if you know something, some new paddler might not and seeing an accident report might make them avoid pitfalls. Reporting an accident can also help inform the way experienced folks paddle too. Case in point... After a fatality in a dangerous sieve on the big south, the number of paddlers running that drop has decreased dramatically due to paddlers being made aware of the severe consequences. We all knew you could pin there, but when the consequences changes from the theoretical to the actual it shifted peoples decisions. 

Think of the people hurt... Many folks stress the need to protect the people close to the deceased from further hurt, thus advocating that investigations and information stop. This potentially ignores the people who could be saved in the future. I'd guess that if people involved in an accident were given a choice to share information that could save others that most would choose to share. In non fatal accidents most paddlers quickly share issues like dangerous logs, pin spots etc, but when fatalities are involved we clam up. 

I think as a community we give lots of lip service to understanding risk and consequences, but when we are confronted with a fatality and the stark consequences of that specific event we struggle to deal with it and frequently shy away from truly facing it head on and dealing with it. 

Im not sure what we should do, but i think we should do less criticism of folks trying to help and do more education and learning on how to dealwith accidents. I think an accident report template is a good idea ( more that river, state, class, craft etc). I also like the idea of having some trained accident investigators to interview folks, but think this may not be practical.

While I'm sure many folks will disagree with me, my experience with accidents across multiple arenas gives me some insight into some major gaps in the paddling community.


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## yojimbo (Oct 12, 2003)

Deep South,

I like the swiss cheese construct and will bring it to our next research lab safety meeting.

Thanks,

Jim


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## Phil U. (Feb 7, 2009)

Thanks for that, DeepSouth.


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## Tom Martin (Dec 5, 2004)

That's a brilliant post DeepSouth. 

Went through the root cause training many years ago, and greatly appreciated the fact that it was not looking to assign blame, but to just report the facts of the event as best as we could figure them out.

Getting info out of agencies depends on the agency. Here in Flagstaff, the local paper has a police log with FDP and Coconino County Sheriff's Dept posting incident reports daily. But the NPS is another animal all together. I have even had AZ DPS and CCSD officers complain to me about lack of info from Grand Canyon National Park law enforcement. Who am i but just an interested citizen, so it's unnerving when i here this. 

There was a Ranger Log in the South Rim weekly newspaper, but maybe 10 years ago the NPS stopped releasing the reports. Then their law enforcement radios went digital, so getting information from GRCA LE has become harder and harder. It actually takes a lot of research. 

All that said, it is very important to get the word out there as soon as possible and as factually as possible, for the reason's you have so eloquently stated.

Thanks again for the post, tom


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## D-Sieve (Mar 15, 2012)

well said deepsouth.
However, I'm certain that sometime I will die. I'm not sure there will always be a lesson attached, or maybe there will be? Just gonna live it & love it the best I can!


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## cataraftgirl (Jun 5, 2009)

I work in the medical profession, and know all about root cause analysis. It's done in a professional manner, with no assigning of blame. It's all about examining the processes involved in a bad outcome, and learning from it. Were protocols followed? if not, why? Are changes in protocols needed? Often the inquiry ends with the knowledge that things were done correctly, that people did their best, and that the outcome could not have been changed. We come out of the process determined to continue following proper procedure and being vigilant and proactive.

My personal philosophy on river accidents is that there is always something to learn, but not always something that can be changed. Being skilled and prepared is the best way to avoid or minimize a bad outcome or event, but it's not a 100% guarantee. We are not always in control of everything. I like deepsouthpaddlers 5 whys. However, you might not always know the answer to why, especially if the information isn't available or complete. That was the problem I saw with the recent thread on a river fatality. Some of the why questions couldn't be answered with the info provided.

Mountain Buzz is a public forum not always known for being tactful. Blame will be assigned for sure. There may be some thoughtful discussion and lessons learned, but there will also be hurtful, counterproductive things posted.


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## restrac2000 (Mar 6, 2008)

Some of the terminology and ideas presented are new to me so I have so research to do.

That said, one thing that is standing out to me is the potential difference between the professional measures and related investigations and recreational environments. Professional organizations/businesses/pursuits are normally defined by codes of operation (i.e. did they follow in-house or international standards at Fukushima, etc) and ethics. Those measures are often what provide an explicit way to analyze cause and effect, i.e. "why". Is that the same in recreational environments where training is from a wider array of sources and policy is largely non-existent? Is the "why" as obtainable outside of the objective hazards of the environment (sieves, etc)? Is it fair or as beneficial to participants and the community at large to approach accidents with that template when the way we operate is so different? I am personally not sure. But I do see a difference between approaching a commercial accident versus a private endeavor for recreation. Most of us enjoy the independence of our private trips which is markedly different from the standards of professional environments.

Do those differences explain why some reporting has been based more on narrative in the recreational realm? I haven't investigated all of the options and the history of accident reporting fully enough to know why different processes are chosen.

Also I would point out in my exposure to recreational accidents rarely is there a black and white line between those advocating respect for participants and those wanting to provide reports in relationship to timing. Both often overlap in their overall desire to know. I also think there is a caveat between the timing of investigating and the timing of reporting. Obviously most people understand how the narrative of an event can change over time and the importance of investigating sooner than later. Its interesting though as the AW sources I found rely on participant submitted reports that can often are not reported to the public for an average minimum of what appears to be about 6 months. 

As far as the timing of reporting, there are explicit objective hazards that benefit the community to know as soon as possible. A new feature or hazard on a river is one such possibility. I think most of us agree that when a previously unknown or new feature emerges it is helpful to the community to report that finding immediately (that seems to happen outside of official reporting on forums like this though). But if investigation does not provide such novel results is there a way to temper the desire of immediacy of reporting? I for one obviously do not believe that "sooner" is always the best way to go about this process as some have stated. Maybe there is more grey in their ideas then is being stated but that is far from clear right now. Hence my curiosity in this conversation.

Thanks for the replies thus far and civil conversation on a potentially difficult topic.

Phillip


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## lmyers (Jun 10, 2008)

Great post Ian. Makes me re-think and take a deeper look at all accidents and the way they are posted/handled on this site.


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## glenn (May 13, 2009)

restrac2000 said:


> Some of the terminology and ideas presented are new to me so I have so research to do.
> 
> That said, one thing that is standing out to me is the potential difference between the professional measures and related investigations and recreational environments. Professional organizations/businesses/pursuits are normally defined by codes of operation (i.e. did they follow in-house or international standards at Fukushima, etc) and ethics. Those measures are often what provide an explicit way to analyze cause and effect, i.e. "why". Is that the same in recreational environments where training is from a wider array of sources and policy is largely non-existent? Is the "why" as obtainable outside of the objective hazards of the environment (sieves, etc)? Is it fair or as beneficial to participants and the community at large to approach accidents with that template when the way we operate is so different? I am personally not sure. But I do see a difference between approaching a commercial accident versus a private endeavor for recreation. Most of us enjoy the independence of our private trips which is markedly different from the standards of professional environments.
> 
> ...


To me the timing is important as a 3rd party reading reports. Recent reports always drive home the reality of the situation more than an old report. Events that happened more than a couple months in the past are history and I form a much weaker emotional tie to the event. Another case for immediacy is the large role weather conditions play in the hazards we face. Providing a high water accident report does little as a reminder to the hazards and precautions that can be taken during high water events when it's august and the only things running are low water dam releases. Same goes for cold weather paddling, elf boating, strainers after recent wind storms and on and on.

Personally when I take a band-aid off I pull it off hard and fast. Thinking about the friends I lost I would have much preferred to have reporting/analysis/discussions and maybe even a few answers very early in the grieving process rather than later. Maybe I'm the exception. I've never lost a close friend during a river trip or something similar though.


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## cataraftgirl (Jun 5, 2009)

Great conversation here folks. I talked with a friend at work today about the Root cause analysis process. She is in management and has much more experience in RCAs than I. She related that the number one thing that leads to a productive analysis of an event is maintaining a safe environment for people to share information. No finger pointing or blame. This allows for an open exchange of information that leads to answering those 5 why questions.


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## j-jo-ber (Nov 8, 2013)

deepsouthpaddler said:


> I think where the paddling community has problems is that few folks understand accident / safety science and they let emotion trump effective investigation/ reporting. Accident investigation and reporting is a mature field in engineering, medicine, and industry and possibly other sports, but people not educated in this miss some key points. Accidents typically have the same form or structure whether its a plant exploding, a train derailing, a guy falling off a ladder hanging christmas lights or a paddler dying on the river. Many see an accident as a random stroke of luck with no cause. Accident science states that accidents are not random dumb luck but the combination of one or more factors that yields an accident. In hindsight almost ALL accidents are preventable.
> 
> ...


A professional duty of emergency response personnel (rescue, medical, police, emergency financial litigation, etc.) is the completion of some variety of incident reporting, usually featuring a first-person narrative. To serve the mental health of these personnel, as well as the accuracy of these reports, a good deal of their preliminary education and professional training is focused on the mental/emotional response to traumatic events, as well as on-site counseling/debriefing as needed. 

Quality control isn’t perfect because it’s retrospective in nature (preparing for the future by learning from the past), but measures like this have shown improvements to the mental health of emergency personnel and the accuracy of their reporting. These are, however, initiatives implemented by professional organizations as an obligation to the public service they provide. 

As many of us run rivers to escape the world of public services, automobiles, and McDonald’s, this form of quality control will fall to personal research and personal implementation. If the timely reporting of river incidents is necessary for the ongoing quality control of recreational river running (a premise that seems to be shared), does anyone involved in this discussion know of any resource that could prepare a trip leader or trip participant for dealing with the fallout of a traumatic incident in the immediate aftermath? I’m not thinking in terms of swift water rescue skills, but in terms of dealing with group dynamics after exposure to trauma and the collection of first person narratives to better serve reporting by third-person entities, etc.?


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## glenn (May 13, 2009)

I seem to remember being provided with a number of post-event support hotlines when taking CPR + First Aid and WRT classes. I'm failing at the internet now and can't find any. These types of hotlines can usually make you more aware of services, support groups and the like in your area.


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## deepsouthpaddler (Apr 14, 2004)

J Jo, I have not seen any paddling specific organized help with dealing with accidents or fatalities. This is a good idea. I have seen experienced paddlers who have dealt with fatalities offer up help to folks who are struggling. This would be a good resource for the community.

I also agree completely with the comments about the need to have an open environment to explore root causes without be judged and demeaned. In the recent closed post, a person who tried to do this was told he was a dick and multiple people raged on him, but he was in my mind following the exact way we should analyze accidents. When folks don't understand the way accident analysis should happen, they get angry.

Perhaps doing an ad hoc community accident pseudo investigation online is what is unproductive. All it takes is one or two internet blow hards to really sour things, as evidenced by the recent at each others throats approach.

What would be good is for paddlers to think about the approach, do the 5 why and root cause analysis with your own party when near misses, accidents or fatalities happen, and share with the online communities and AW. 

AW does publish semi annual fatality reports, but the initial reports from paddlers to AW are typically done much sooner. In many cases AW is alerted to the fatality because it is posted on Mountainbuzz, or other message boards.

As an example of the kind of untapped power out there... I have had lots of discussions with other paddlers about helmet safety, which helmets dampen the hits the best, and which helmets ring your bell to easily. If paddler injuries noted what type of helmet they were wearing and were stored in database format, you could eventually with enough data look at which helmets might be linked to the most injuries. There is power in data that we simply don't have right now.

Another example of this type of thought process is the guy who designed the WRSI helmets after his son died. Why did he die? Injury to the forehead. Why did he get a forehead injury when he was wearing a helmet? Helmet straps and fit was poor. Why was the helmet strap and fit poor? Bad design that lead to easy shifting of helmet. Now, many helmets come with the occipital adjustment to help get a great fit. This is the type of logical thinking we can all benefit from.


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## cataraftgirl (Jun 5, 2009)

deepsouthpaddler said:


> I also agree completely with the comments about the need to have an open environment to explore root causes without be judged and demeaned. In the recent closed post, a person who tried to do this was told he was a dick and multiple people raged on him, but he was in my mind following the exact way we should analyze accidents. When folks don't understand the way accident analysis should happen, they get angry.


The best way to get people to have an open exchange of information is to provide them with a safe environment to do so. Starting the conversation by firmly planting blame on the group involved in the incident doesn't do much to foster dialog. I believe it was the delivery that angered people, not the desire to learn from the analysis of the event. I'm all for learning and applying that knowledge in the future, but I don't think saying "These people really screwed up. What can we learn from their screw up?" is the best way to start. But this is the Mountain Buzz, and tact isn't always our strong suit.


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## cataraftgirl (Jun 5, 2009)

One other observation....
It's strange that, when people share events that had a good outcome, the sharing of knowledge comes freely and in a positive manner. I'm thinking of the recent thread & video where a group of kayakers worked calmly and in an organized manner to rescue their fellow paddler. There was a great exchange of information and positive feedback. I learned a ton from that thread. There weren't any negative comments about how he or his friends messed up and got into such a terrible situation. It's a shame that when something bad happens, we can't separate ourselves from assigning blame. Let's not talk about how a group failed their friend, let's talk about what circumstances led to the event, what things were within the control of the group and what things weren't, what could have been done differently. Let's start with as many correct facts as possible so that we don't draw incorrect conclusions. I think that's the way to approach event analysis and learn from it.

OK, enough philosophy for me for one day. All this thinking is making my head hurt.....but in a good way. Critical thinking & discussion is good for the brain cells. Peace Out.


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## cadster (May 1, 2005)

Some of the same ideas being expressed here in regard to snow avalanche accidents:
http://devononeil.com/Stories/Breaking%20Bad.pdf


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## cataraftgirl (Jun 5, 2009)

cadster said:


> Some of the same ideas being expressed here in regard to snow avalanche accidents:
> http://devononeil.com/Stories/Breaking%20Bad.pdf


Great article.The quote from Bruce Tremper sums up a lot of how I feel about accident reporting and analysis. I think there are many lessons to be learned from accidents. We can all work hard on skill, preparation, and decision making. All that learning can help us avoid or minimize the dangers that are inherent in the wilderness. However, none of that is a 100% guarantee that something bad won't happen. I feel that saying every death on a river is the result of failure and can be prevented is a bit arrogant.

“We all want to believe we’re so much more in control of things than we actually are,” says Bruce Tremper, in his 27th year as director of the Utah Avalanche Center. “I’ve noticed it for years. I think it needs to be talked about.”


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## restrac2000 (Mar 6, 2008)

The article does a good job at reinforcing what avalanche educators have been doing for several years now: educating folks on the human dynamics of risk management. Understanding how and why we make decisions is a major component of outdoor sports. It goes well beyond hard skills.

Using that foundation to approach accidents investigation and reporting seems to be a prudent idea. 

Phillip


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