Problem Solving Community Accident Reporting - Mountain Buzz

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Old 12-08-2013   #1
cedar city, Utah
Join Date: Mar 2008
Posts: 2,261
Problem Solving Community Accident Reporting

A recent thread has exposed several themes that many of us care about. I thought it prudent to remove further conversation from the specificity of that event yet found the broader themes important enough to warrant that back and forth “dialog” some of us benefit from. So…..

What I have heard thus far:

1) The community largely supports sharing accident information in a public setting like this forum.
2) Many of us don’t believe that resource has been productively and effectively pursued to this point.


1) Issues of balance regarding individual privacy and public desire to know, principally seems to be an issue of timeframes.
2) Authority: who collects and compiles information and if need be pursues interview material
3) Style of presentation: diverse options exist and all have their pros and cons

That is just some of the issue I have seen at the core of the broader issue of accident reporting discussed as I have seen thus far. If people are truly interested in filling in a gap then I have to ask:

1) Do we believe a new organization or group of people is needed to provide this service?
2) Is the broader community willing to support such an endeavor with time, financial resources or in kind donations?
3) Are people willing to go about addressing the issue in a formal manner that hopefully finds a different balance between current efforts and the constructive criticisms that are being addressed?

If people are interested in any fashion than I would think this winter could be a great opportunity to lay some groundwork. It would appear that we don’t need to reinvent the wheel but that there is potential for improvement. This could be as small as a “recommended” format for Mountainbuzz or a resource for the region. If people are interested then here are some of my personal recommendations as both a boater and participant in recreational accidents:

1) Make it a formal process with detailed outline of procedures
a. This could help address sensitivities associated with timeframe
2) Make it committee oriented (if scale is such that warrant s)
a. This aids in producing oversight, reduces personal conflict and hopefully provides information that is more objective than subjective
b. Would specifically allow individuals to recuse themselves yet reduce the possibility of not reporting (which I personally agree is undesirable in the long run)
3) Base it on voluntary submissions by participants of event
a. Provide a consistent formatting (questionnaire, online resource, etc)
4) Provide a formal means to edit and provide public feedback (constructive and positive)
a. Current informal approach does not lend itself to thoughtful review once the information has been made public. The nature of the internet and these forums often seems to exaggerate social problems instead of remedying them. It would seem providing a “lessons learned” approach to accident reporting would need to be formally vulnerable to that very process itself.
b. Have a system of review for this information which allows/encourages relevant people to recuse themselves

If people aren’t interested than maybe we can group some community feedback and resources to aid the existing providers of information in the whitewater community. I will admit I don’t personally “know” the best approach but do sincerely believe something better could be done. I think current efforts are either falling short or producing conflict that could be avoided in the future.

Any thoughts or interest?

Phillip Rhoades

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Old 12-08-2013   #2
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BZN, Montana
Paddling Since: 2008
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Posts: 1,493
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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Old 12-09-2013   #3
Radville, Colorado
Join Date: Sep 2013
Posts: 27
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, 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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Old 12-09-2013   #4
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BZN, Montana
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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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Old 12-09-2013   #5
Boulder, Colorado
Join Date: Oct 2003
Posts: 189
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.


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Old 12-09-2013   #6
Denver, Colorado
Paddling Since: 2004
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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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Old 12-09-2013   #7
Boulder, Colorado
Join Date: Oct 2003
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Deep South,

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


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Old 12-09-2013   #8
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Thanks for that, DeepSouth.
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Old 12-09-2013   #9
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Flagstaff, Arizona
Join Date: Dec 2004
Posts: 928
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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Old 12-09-2013   #10
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Boise, Idahoer
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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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