UPDATE: 'Selfless' kayaker...

...drowned helping friend; coroner flags precautions to take when kayaking around Singapore

https://www.channelnewsasia.com/.../chew-jia-tian...

The investigation into the tragedy comes to a close.

Overall, I find the conclusions and precautions listed by the coroner are expected and reasonable.

Again, there seems to be undue focus on the deceased's PFD crotch strap, which was found to be 'tucked into front and rear pockets and unused'. I do not dispute that equipment should be used as designed; however, there are instances when certain parts of equipment may present hazards of their own e.g. the crotch strap may get caught on some underwater object. [Yes I'm nitpicking here.]

It is important to remember that this incident occured due to a confluence of unfortunate factors and errors.

It is good to read that "Despite the opinion of a principal marine investigator who said Ms Chew had 'bought a defective personal flotation device', the coroner found that the life jacket was not defective." How this person arrived at such a conclusion is baffling at best and irresponsible at worst.

Outdoor and adventure activities can be safely enjoyed - let's all continue to be vigilant, aware and guard against complacency.

Stay safe, fellow practitioners and adventurers!

==============

Take a look at my earlier post about the incident:

https://oaemusings.blogspot.com/2024/07/life-jacket-came-off-kayaker-who.html

Life jacket came off kayaker who...

 ...drowned in waters off Sentosa: Coroner's inquiry (ChannelNews Asia, 4 July 2024)

https://www.channelnewsasia.com/singapore/kayaker-died-drowned-waters-sentosa-life-jacket-came-coroner-inquiry-4456791

I am concerned about the apparent emphasis on the deceased’s life jacket, which should more accurately be known as ‘personal floatation device’ or PFD. This distinction is important, as I will elaborate below.

Firstly, my heart goes out to the deceased’s family; I am only trying to open some different perspectives about this sad case.

The article listed several factors that led to the unfortunate tragedy:

·       The choppy sea conditions and strong currents.

·       The presence of the blue barriers.

·       Ms Chew’s improperly-worn PFD.

·       The competency of the kayakers – although from the article, I failed to see the relevance of Ms Chew’s inability to perform a ‘roll drill’. [Incidentally, this is the first instance I’ve come across this term. A Google search resulted in no hits linking this term with kayaking. The Singapore Canoe Federation’s website also does not mention this term. I daresay that even experienced kayakers may have difficulty performing a ‘roll drill’ when pinned strongly against bobbing blue barrels.]

The factors that are not mentioned or at least, not dealt with in any meaningful way:

·       The group’s familiarity with the locality or lack thereof – okay, this was mentioned by the expert witness.

·       The group’s apparent lack of kayak safety equipment like tow ropes, bailers (to remove water from inside the kayaks) or even whistles – however, they may not have been trained to use such equipment.

·       The group may not have sought advice from experienced kayakers who have paddled in that area.

The article quoted sports goods retailer Decathlon as saying: “When a user capsizes, they are meant to face skywards and hold onto the life jacket with their hands.” I have attained a 3-Star Award in kayaking and I have never once been instructed in such a way.

It is curious that the Singapore Canoe Federation’s views or expertise did not feature  much in this article.

I agree that there is a likelihood a PFD can come off a person’s body as described by Decathlon. However, there are any number of reasons this can happen and not securing the crotch strap is but one of them.

I personally think that Capt Cheong’s speculation that Ms Chew had bought a “defective” PFD (I refuse to use the words ‘life jacket’) is irresponsible. It is plausible that between the time she purchased the PFD from Decathlon and the tragedy, she may have used it several times and on one of those outings, the PFD may have become ‘defective’ and she chose to ignore it.

This is why I’m puzzled by the attention lavished on the PFD. If I was Decathlon, I should be very wary how this report may affect me.

I do recognise that this article is reporting on an ongoing investigation and “the coroner will deliver his findings at a later date.”

Hopefully, reason will prevail.

-------------------------------------

With regards to this ChannelNews Asia report, I encourage my practitioner friends to help educate the wider public to reduce misconceptions and thwart negative notions about our industry.

Some clarifications about the 2-Star Award in kayaking, overseen by the Singapore Canoe Federation:

In 2-Star Award proficiency, a kayaker is expected to demonstrate “capsize and wet exit with retention of kayak and paddle’. There is no requirement for kayakers to know how to tow another kayaker.

Only in the 3-Star Award is a kayaker expected to “demonstrate 3 reliable consecutive rolls on flat water”. Another skill required is to “demonstrate the use of long tow” i.e. use a specialised tow rope to tow another kayak (with the kayaker inside).

[Singapore Canoe Federation, https://scf.org.sg/disciplines/sub/personal-skills-star-award-course)

 

What is the difference between a Life Jacket and a Personal Floatation Device?

A Google search will throw up many hits, but these two links are a good start:

https://mustangsurvival.com/pages/pfd-classifications

https://www.youtube.com/watch?v=bx0YRCvdY7I

If I may offer a summary: Life jackets may be worn by people across a large spectrum of physiques and abilities, and even helps a person who may fall unconscious. PFDs are meant for users who have received some training in a particular water-based activity or work context. They are meant to be comfortable and allow freedom of movement so the users can go about their activity or work without undue impediment.

As always, I welcome constructive and considered comment.

[Thanks to Chew Hiap Iuh who alerted me to the article just as I was preparing to go home for the day, which I changed my mind about and decided to put up this post.]

FAQ on...

...the adoption of ACCT standards by the Ministry of Education to govern operation of challenge courses in Singapore.

In the light of the CNA article: “After outdoor mishaps with schoolkids, instructors now required to go through detailed checklists” and recent incidents involving challenge courses, I attempt to provide an overview of how the Ministry of Education decided to adopt a set of standards devised by a US-based professional association, the Association for Challenge Course Technology (ACCT).

I am grateful for the contributions of Afiq Samsudin, Selamat Jufri and Chew Hiap Iuh to this article, especially in the area of incorporating ACCT standards into challenge course operations at MOE and Republic Polytechnic and the discussion of ‘best practices’ and ‘standards’.

Any opinions expressed herein are purely my own as a practitioner.

I assume full responsibility for any errors of fact and welcome corrections.

ACCT Article

The news article describes...

...the outcome of a zipline incident that happened in 2020.

Given an afternoon with free-flow coffee, I'm sure we can come up with a long list of ways to mitigate the risks inherent in the zipline activity. However, sometimes we may overlook the principle of 'collective safety'.

First, let me state upfront that the burden of responsibility lies mainly with the activity instructor and organising entity, because the participants have no prior training or experience - the duty of care aspect is not in dispute.

However, it is not incorrect (and I daresay even desirable) to encourage participants to play a more active part in the safety process.

Allow me to illustrate with two examples that might be applied to the zipline activity:

1. Sharing a mnemonic with participants e.g 'ABCD' (Anchor, Belay, Carabiner and Device) so that both participant and instructor help each other ensure that the process is complete. Both can recite the mnemonic at the despatch point - this helps the participant to be more assured, and the instructor has an additional (non-threatening or -pressuring) way to ensure he/she is doing the right thing.
2. Putting up pictures or posters of correctly-worn harnesses, locked/unlocked carabiners etc. allows the participant to identify visually if the processes/actions are correctly applied. The instructor can ask the participant to verify using such visual aids. Again, this could help with reassurance on the participant's part and compliance on the instructor's part. At the very least, it's something else to engage participants waiting their turn on the zipline.

The above can of course be tweaked to match the participants' cognitive ability.

Personally, on the ziplines I've worked at or visited, no. 1 is quite common, but for no. 2, not so much (if at all).

There is great potential for getting participants to be more actively involved in observing safe practices in activities. Some points for consideration:

1. While safety is of course a serious matter, it can be made fun or less-threatening in its enforcement.
2. Practitioners have to put aside their ego and adopt a more collaborative stance with their participants.
3. There should be no doubt or misunderstanding that the final say lies with the activity instructor.

This is why I use the words 'collective safety' rather than 'collective responsibility', because the latter is neither entirely relevant nor necessarily true.

https://www.channelnewsasia.com/singapore/freelance-instructor-jailed-schoolgirl-fell-11m-flying-fox-suffering-fractures-4149081?fbclid=IwZXh0bgNhZW0CMTEAAR0qVrGLq176MU3-brBBq6ZW0iKHfsmFBHFC_y0a195JWvQWnMlcPMWgE44_aem_AQLQNAqKXuefY1ZubzLjCdNJjNcR6Wonf-OTgjvimpS7-V_e4f8hg9tzKW1qRmsuy2Jdfhb3yLu9bewGB8IyoNbJ

I thought a response...

...to my recent post deserves its own posting. I hope you don't mind Jeff Baierlein if I exercised my editorial prerogative to do so. Jeff is well-placed to offer a perspective for the edification of practitioners (including my own!). [Check out Jeff's bio here: https://courses.viristar.com/our-team/]

I had written my post adopting a micro or practitioner/operator point of view. When I wrote "the burden of responsibility lies mainly with the ground staff conducting the activity, and the organising entity", I personally adopt the mindset that, at the moment of despatching a participant on the zipline, the buck stops with me. My actions (as a result of training, regulation and experience) had led the participant and I to this critical juncture, after which whatever happens, happens.

But I certainly believe in the chain of safety and the macro perspective as so well described in Jeff's response below:

"A thought about who else can support good safety outcomes: the research into safety indicates that to most effectively reduce the likelihood and severity of incidents, improvement efforts should be made at all levels of the system in which the incident occurred. The complex socio-technical system generally is understood to include government legislation and regulation (and its enforcement); industry associations (in this case examples include ACCT and OLAE) and their organizational accreditation and practitioner certification/qualification schemes, as well as Codes of Practice; the provider (company) organizing the activity, including its policies, procedures, safety culture and standards; the staff directly conducting activities (in this case, the dispatcher/facilitator), and the nature of them design of work tasks. (This primarily from AcciMap and its variants).

There is not good evidence to suggest that the burden of responsibility lies mainly with the ground staff conducting the activity, and the organising entity.

We can see a positive example of this systems-informed approach with the recent follow-up to the incident at Safra Yishun, where organizational accreditation requirements (ACCT) were strengthened, practitioner qualifications (ERCA/ACCT/other) were strengthened, and the government, association leadership and the private sector also became involved in strengthening adventure safety standards across the adventure industry. Having the government support the private sector with workforce development in the post-pandemic context is another part of this systems-informed approach.

One of the ways to understand a safety mishap is to see the commission of an error as a symptom of an imperfect system, rather than simply a failure of the person directly involved. So we must look more deeply, if we wish to help prevent future incidents. Were safety laws and regulations sufficient, and appropriately enforced? Were industry association safety guidelines/codes of practice sufficiently well-developed and disseminated? Do a sufficient percentage of operators follow those guidelines/COPs? Is there a third-party audit system to help ensure that standards are clear, and unambiguously met? Are training bodies sufficiently resourced to make trainings available, and do operators/practitioners have the resources to ensure staff are trained?

In many cases in SG, the answer to these questions is yes, because of the good work of various entities, from training institutions to government to the private sector. And the adventure sector, as you know, is actively engaged in a process of further improvement.

Locking up a dispatcher/facilitator who makes an honest human error is not well-correlated with preventing future incidents. Applying interventions at all levels of the system, however, is."

Regarding the punishment meted out to the instructor, a friend asked me yesterday if I thought it was 'harsh'. I replied (and this is my personal opinion):

1. I think it can’t be helped especially with the recent sentencing of the Camelot instructor. A message had to be sent to the industry and the public and it had to be this.
2. Such sentences may encourage realignment of mindsets… so those who don’t have the right attitude might buck up or leave the industry. Practitioners who do their job properly or organisations with adequate regulatory and training regimes should not have to worry. I am however concerned about the possible imposition of draconian measures or regulations that assume our current industry practices are weak or necessitate more oversight.

[The above part is especially difficult to write because I know the instructor involved in the case. I don't know the particulars of the case, so I'm really just sharing my thoughts without prejudice to the instructor or anyone else involved.]

I can understand...

...if this article is not written by someone with more intimate knowledge of the profession, but some parts of the article got me wondering:

1. Is there any significance to describing the instructor as a 'volunteer'? What difference does it make?
2. The instructor was charged with causing "grievous hurt to Jethro through a rash act by illegally omitting..." Are safety procedures also 'laws'? I'm not a legal expert, but does this mean that if practitioners, in the course of their duties, overlook a procedure (let's assume it doesn't result in serious consequences), they are in fact breaking a law? Or is it that the nature of the consequence determines if the act (of overlooking a procedure) is unlawful?
3. "According to the prosecution, a participant who had worn the harness properly would have been able to climb back onto the obstacle more easily as the person would have been in a higher position." Particularly with the use of daisy chain straps, this highlights the importance of attaching it to a participant such that there is not too much slack. I have seen many cases where, due to time or participant pressures or maybe even due to poor training, instructors just use the full length of the daisy chain rather than assess the individual participants' heights and attach accordingly.
4. There were two other instructors stationed at the towers in between the obstacles. If the instructors are required to observe participants negotiating the obstacles, then they should have noticed that Jethro was not properly harnessed and either a) asked Jethro to turn back to the despatch point so that his harness can be adjusted properly or b) when Jethro arrived at the first tower, the instructor there could help adjust his harness.
5. While Hakim's lawyer said that "he had exercised a poor split-second judgment call", the other possible area of poor judgement is the time that elapsed from when he fell off to being lowered to the ground from the obstacle, which was about 30 minutes. Typically, in high ropes rescue scenarios that require lowering a participant to the ground, the whole procedure should take between 3-5 minutes. It appears that the decision to lower Jethro took too long and came too late.

I welcome comments that may help further understanding of this.

https://www.channelnewsasia.com/singapore/safra-instructor-acsi-student-rope-obstacle-course-death-4047391?fbclid=IwZXh0bgNhZW0CMTEAAR3FpClLI8wMFBrwXBOrZXg2X3RLPzwT6JWRhTHyvlUJsNwl2kBcWAeguTI_aem_AQKAJT759cybpa2-wovauKWKHCpZFdTDTPN7aT9h3PTJAwDkyCJ8fQ9UASUoheYkiw8gnZvFpOI74GCsq7Od69jK

It is not so much the article itself...

 

...but the comments that got my attention. I am aware that social media can be a brutal environment - an online court of public opinion where harsh judgment is passed down in the absence of testimony from the ‘accused’.

I read all 74 comments (at the time of my reading the ChannelNewsAsia FB post) and accompanying replies. I can say that there was not a single supportive comment and that is to be expected. Mistakes were made, a life was lost and there is justifiable outrage.

Reading the comments, I had a variety of feelings; mostly hurt and apprehension but there was also hope.

I felt hurt because:

• Since our industry is small, I am acquainted with many of the companies and organisations and many of the leaders and staff are friends. I can confidently say that I’ve not met an outdoor education professional who is cavalier about the burden of responsibility they carry when they are with participants. At numerous gatherings or conferences, the phrase “when one incident happens, the whole industry suffers” often pops up in conversation or workshop presentations about safety. To say that our industry is ‘unsafe’ is a gross mischaracterisation at best, a spurious allegation at worst.
• The young people who join the industry are energetic, enthusiastic and passionate. Many started their outdoor education careers as volunteers e.g. cadet inspectors in the National Police Cadet Corps, rover leaders in the Scouts, and the like. A fair number wanted to become an outdoor educator ‘because my Outward Bound instructor inspired me’. We risk killing our potential source of committed, dedicated outdoor education professionals if we allow the seed of fear to grow in them, making them wary of joining our industry - this will infect those who might be considering a career in the industry.
• I teach in the Diploma in Outdoor and Adventure Learning at Republic Polytechnic. We lecturers help our students understand that an outdoor educator is not just fun and games and working in the outdoors; they come to realise that they have an amazing opportunity to help others grow, just as they themselves have done on their own journey to graduate from the diploma. And this opportunity comes with a heavy burden of responsibility but oh, the potential rewards are priceless.

I felt apprehension because:

• Our industry has been damaged by this incident (and it has been before from past incidents). How can we come together and recognise that we face an existential threat? The fact that the Ministry of Education felt like it had to open its own outdoor education centres is one example. We say that we don’t need high-handed oversight or tedious rules and regulations, but clearly have some work to do in convincing the powers that be as well as the general public.
• It is acknowledged within (and more than likely, outside) the industry that it does not offer the most competitive remuneration to practitioners. It is a vicious cycle - the company cannot ask for reasonable (what is ‘reasonable’ is a discussion for another day) fees because of the unique nature of the market in Singapore, so it cannot afford to train or retain a viable pool of professionals, as a result many practitioners become freelancers, and freelancers don’t get paid ‘reasonable’ rates, and they often have to foot the bill for training or certification,...and so on and so forth.
• There is still a lot of ignorance and misunderstanding of what we do in our profession.

I feel hope because:

• In 2015, the Outdoor Learning and Adventure Education (OLAE) Association was formed. They have a Code of Conduct (a first attempt at some kind of ‘national’ code for outdoor education companies and practitioners) and a set of standards governing programmes and activities was freely circulated among the industry and outdoor education community.
• While the national Outdoor and Adventure Education (OAE) Council was formed under some challenging circumstances, it should be hailed as the first serious effort to bring together all the major stakeholders (government and private) in Singapore’s outdoor education domain. Some items on the council’s to-do list are: instituting national standards, formulating practitioner training and certification syllabi and promoting communication and cooperation among the stakeholders. These efforts will bring about welcome and positive developments for professionalism and safety in the industry. I am optimistic because I know many of the members currently sitting in the council. But I am also mindful the journey can be long and arduous.
• More than a few of the students I teach possess the attributes I consider important in an outdoor educator - enthusiasm, open-mindedness, authenticity, empathy, resilience among many others. When they join the industry, they (and others like them) will be excellent role models for the people they work with.
• If we can accept that we have a collective responsibility to rehabilitate and repair our damaged reputation, then we must use our collective voice to help educate the wider community and demonstrate that we are professional and perform an important social role. There will be always be bad apples in the basket - which industry doesn’t? But this can be managed with proper oversight, management, training and good mentoring.

Pretty much my entire professional life revolves around outdoor and adventure education and I love what it has done for me, and what it can do for others.

https://www.channelnewsasia.com/.../volunteer-instructor...