...drowned helping friend; coroner flags precautions to take when kayaking around Singapore
18 August 2024
UPDATE: 'Selfless' kayaker...
04 July 2024
Life jacket came off kayaker who...
...drowned in waters off Sentosa: Coroner's inquiry (ChannelNews Asia, 4 July 2024)
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.]
18 April 2024
FAQ on...
...the adoption of ACCT standards by the Ministry of Education to govern operation of challenge courses in Singapore.
The news article describes...
...the outcome of a zipline incident that happened in 2020.
- 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.
- 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.
- While safety is of course a serious matter, it can be made fun or less-threatening in its enforcement.
- Practitioners have to put aside their ego and adopt a more collaborative stance with their participants.
- There should be no doubt or misunderstanding that the final say lies with the activity instructor.
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/]
"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."
- 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.
- 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.
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:
- Is there any significance to describing the instructor as a 'volunteer'? What difference does it make?
- 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?
- "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.
- 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.
- 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.
It is not so much the article itself...
- 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.
- 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.
- 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.
I wish...
I also applaud the OAE Council's plan to support the industry with a 'workforce development roadmap' - this will boost professionalism and hopefully raise the profile of practitioners and the important work they do in people development. Subtext: practitioners can get paid better.
First time I've come across...
...this. But our fellow professionals in the ropes access industry or sport climbing and challenge course world may have embraced this service and installed the app already.
It is indeed unfortunate...
...if the industry only seems to learn best when incidents or tragedies occur. If this sort of attitude (in the industry) continues, then it's only a matter of time when the next tragedy occurs.
19 January 2024
Instructor sentenced to jail over participant's death
[Article - https://www.channelnewsasia.com/singapore/safra-instructor-acsi-student-rope-obstacle-course-death-4047391?fbclid=IwAR0bNq9JC7WZyxSFB_Rx0plDbFxyhQCL3TSFZVTS3vndE8ymY4EYAIryrcA]
- Is there any significance to describing the instructor as a 'volunteer'? What difference does it make?
- 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?
- "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.
- 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.
- 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.
Article: How Risk Management Is Sucking The Life From Kids' Paddling Trips
Reading this, the feeling of frustration comes through quite strongly. Apart from some false equivalences and whataboutisms in the article, there are some pertinent paragraphs.
To me, the key points are:
- Risk assessment is an established and widely accepted practice, but it is often seen as a bureaucratic burden or a document to CYA. (Cover Your A**)
- There is a lingering lack of trust placed in the people who perform the assessment and outline the mitigation strategies. It is worth noting that risk assessment (ideally) is a group effort, bringing in collective wisdom, buy-in and accountability.
--------------------------------------------------------
From Paddling Magazine
https://paddlingmag.com/stories/stop-sucking-life-kids-paddling-trips/
No more outings for the outing club. This was the gist of
the many newspaper headlines in April when Penn State University shared its
controversial risk management review of its 79 student clubs.
While the university publicly acknowledged the many benefits
students gain participating in outdoor activities like hiking, backpacking and
paddling, it also stated the university would no longer allow the 98-year-old
Outing Club to organize student-led, outdoor trips.
Campus Recreation at Penn State remains focused on providing
as many opportunities in the outdoors as possible, while also keeping safety as
a priority,” the statement read. The Outing Club, as well as Penn State’s
caving and diving clubs, were deemed to have “an unacceptable level of risk in
their current operation model.
IT’S ABSURD FOR A SCHOOL BOARD TO APPROVE A YEAR-END,
CAPSTONE PADDLING TRIP FOR STUDENTS WITH THE CAVEAT THERE IS NO SWIMMING
ALLOWED, EVEN IF EVERYONE WEARS A PFD
The university’s martial arts and rifle clubs were allowed
to continue. The Penn State Outing Club decision received a lot of press, but
it’s just one example in a trend sweeping across North America.
For more than a decade, there has been a noticeable erosion
of the joy factor on guided youth paddling trips. The culprit is the risk
management frenzy in our risk-averse society. These decisions are often made by
school board officials with a fear of litigation and a general lack of
familiarity with outdoor environments and activities.
Overbearing risk management plans are diluting the outdoor
experience. And from recent stories of school- and camp-organized trips, it’s
not surprising if a kid goes once and never wants to participate again.
It’s absurd for a school board to approve a year-end,
capstone paddling trip for students with the caveat there is no swimming
allowed, even if everyone wears a PFD.
Other programs mandate youth on trip are not allowed to
handle knives—pocket knives and kitchen knives—or stoke the fire. If kids can’t
swim, tend to the fire, whittle or help with dinner—what are they left doing?
Probably wishing they had Snapchat.
There are many benefits to learning to manage risk. In
healthy doses, outdoor risk builds confidence, independence, self-regulation
and other life skills. Are the real risks students face every day on and off
campus—driving to school, for example—smaller than those they would experience
on an organized paddling trip? And are they providing comparable benefits?
Certainly not.
Contextualizing risk is important. According to the National
Safety Council in the United States, in 2009 there were 35,000 motor vehicle
fatalities, of which approximately 2,000 were children under the age of 16.
There were also 5,300 pedestrian fatalities, 8,600 fatalities from
unintentional public falls, 4,500 fatalities from unintentional public food
poisoning and 800 fatalities while bicycle riding.
Those numbers might sound scary but remember the U.S. had
306.8 million citizens in 2009. Approximately 610,000 died of heart disease the
same year. In the many real risks we encounter every day, outdoor recreation
barely makes the list yet receives disproportionate outcry.
A 2014 report by the NCAA revealed nearly one in 10 of the
United States’ 70,000 college football players reported suffering multiple
concussions during their college career, which is linked to long-term brain
damage, including higher rates of dementia. Why is an elevated risk of
injury—especially traumatic brain injury—acceptable on a sports field? Colleges
aren’t keeping stats on concussions in outdoor adventure because they’re so
rare.
We need to stand up for paddling and its minimal yet
inherent risks. These are inextricably linked to the joys and benefits of the
activity itself. As paddlers, we need to help schools, camps and community
groups move beyond a narrow safety-only focus.
If meeting safety standards is the sole mark of success for
a paddling trip, the bar is set very low. Should safety be a given? Yes. All
trips must be safe. Safety first, but not safety only. As safe as necessary,
but not as safe as possible. Let’s then move onto higher aspirations, goals and
motivations. Why not instead focus on instilling joy and a love of the activity
and the landscape.
To complement and parallel the many outdoor adventure risk
management conferences, we need joy management conferences. Time spent with
other guides, teachers and club leaders discussing the merits of a particular
campfire game, messy desserts and the best swimming holes. Time spent on
ensuring the next generation learns to cherish wild places, instead of fear
them.
On the slippery slope we’re descending, risk-averse
decisions could become paddling-adverse programs. And this would be joyless for
all.
About the authors
Bob Henderson, Ph.D has taught outdoor education at
university for more than 35 years. He is the author of Every Trail Has a Story:
Heritage Travel in Canada and More Trails, More Tales. For more information
visit www.bobhenderson.ca.

