In his article “Learning from accident analysis: The dynamics leading up to a rafting accident”, The Journal of Experiential Education, August 1998, Vol. 21, No. 2, pp. 86-95, the author Johan Hovelynck makes the point that accidents can be attributed to differing aspects of group and organization activity, called “product”, “process”, and “procedure”.

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“Product” is defined as the intended result of the activity, and the technical aspects directly related to the activity.  “Product” is stated to included various technical aspects, such as equipment and hard skills (such as kayaking skills).

“Process” refers to behavioral aspects of the activity.

“Procedure” refers to the degree and type of organization required to accomplish the desired goal of providing the “product”.

The author makes the point that while many believe the root cause of incidents to be based on technical skills, or lack thereof, he concludes that the cause of many incidents may result from the interaction of all three of “product”, “process”, and “procedure”.

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With regard to a rafting accident which forms the basis for the article, the author notes that it was the result of a number of factors, including (1) a take-out point for the rafts immediately preceded Class V rapids, leaving no margin for error, resulting in the collision of an unsafe act and an unsafe circumstance (“product”) upon missing the take-out point and the subsequent capsizing of the raft; (2) the selection of an unfamiliar section of the river for rafting; (3) the supervisory authority was shared by two guides, resulting in less than optimum communication between the two, and unsatisfactory briefings of the participants; (4) the guides were unfamiliar with each other; and (5) the accident occurred at the end of the trip when attentiveness may have been diminished.

It was concluded that the accident was the result of a combination of factors, none of which might have been a sole cause, and that while absence of technical skills is frequently cited as an accident cause, “procedural” and “process” issues should not be ignored.

The takeaways for unit leaders are several, when planning an outdoor event.

First, make sure the “product” is well-conceived, and is appropriate for the skill level, experience, and maturity of all participants (adults and youth).

Second, put into place a “process” that will enable the “product” activity to be successfully managed, paying attention to expedition behavior, discipline, and qualified supervision, for example.

And, finally, have in place a “procedure” or organizational structure that forms the supporting basis for the activity to enable the activity to be successful.

Have a safe and successful outdoor program!

Was the incident the result of product, process, or procedure?