In a story from 2002, two members of a church camp canoeing group tragically perished at the base of Upper Basswood Falls in the Boundary Waters (pictured below) – one a camp participant while swimming at the base of the falls while wearing two PFDs, and the other a staff member heroically attempting to rescue the first.
The camp executive director was quoted as saying with respect to the tragedy: “We’ve been running this program for 40 years and this is the first accident we’ve had. Everything was done exactly according to protocol.“ Yet, tragically, there were still two deaths.
This incident raises several issues, one being that the combination of the environmental hazard (waterfalls) and people = risk.
The extent of the risk must be determined at the time the hazard is confronted, based on several factors, such as, in this case, the swimming ability of the participant, the depth of the pool of water, the flow rate of the water, the severity of the hydraulics at the bottom of the falls, the temperature of the water, to name a few. Clearly, the risk presented by a particular falls changes with time, and is not constant, and thus cannot be assumed to be the same year to year.
Which raises the issue of “following a protocol”.
Having a set protocol (by definition “the accepted or established code of procedure or behavior in any group, organization, or situation“) for a particular event is an appropriate way for a group in the wilderness to begin thinking about how to address a hazard which confronts the group.
Generally, protocols are directed to specific actions (driving the participants), specific activities (swimming, boating, climbing), and specific risks (environmental extremes, cold water, fast water, lightning). From a Scouting standpoint, think The Risk Zone (driving), Safe Swim Defense, Safety Afloat, Climb on Safely, and Weather Hazards.
The protocol is a foundational aspect of the standard of care to be exercised by the leaders of the group. But, without more, merely having a protocol in place may provide a false sense of security. It is only the beginning of how to think about the conduct of an activity, not the end.
For instance, it may be easy to say “when we are at this place, doing this activity, following this protocol, we will always have a good result!”
Perhaps. But perhaps not. Particularly if it is the location that drives the protocol, while ignoring existing environmental conditions attendant to the location, any relevant gear issues, and how either or both affect the participants during the activity.
Protocols are generally initially determined under some set of specific baseline conditions, taking into account the effect of those conditions on the participants, to provide a margin for safety. And, having a protocol in place presumably accounts for those situations where different decision-makers of a group (such as members of a camp staff) repetitively confront the same hazard, but at different times, thus ensuring that the hazard is dealt with in a uniform, predictable manner time after time. Protocols are also useful when the it may be inappropriate to rely solely on the judgment of the decision-makers, who may be too inexperienced to exercise the appropriate judgment under the requisite circumstances.
But, if the decision-makers are accustomed to following the protocol (such as having done the same activity many times without incident) without paying attention to, or perhaps not understanding how, those conditions might render the protocol ineffective from the standpoint of safe conduct of the activity, bad things may (and sometimes do) happen.
This may particularly be the case if those who established the protocol are not the ones routinely conducting the activity (e.g., those remaining in the camp office), and who may have little perspective regarding how the protocol operates in a real world environment.
Based on the stated facts of the above story, the author will assume for the sake of this discussion (correctly or not) that the “protocol” followed was permitting swimming at the base of the falls “only while wearing a PFD”. The PFD may have been thought to be an adequate “barrier” to drowning, particularly since the camper was wearing two PFDs. Unfortunately, the conditions (for reasons unstated in the article) apparently overwhelmed the assumed protective effect of wearing PFDs for the two participants, despite the group “following protocol”.
As has been demonstrated by several stories, following the same protocol, without incident, year after year, does not mean that the protocol is incident-proof, or provides an impenetrable barrier to any and all tragedy. In fact, it may do just the opposite, providing a false sense of safety, causing the group to ignore the potential effect of existing, new, or enhanced hazards.
It is surprising how many stories of tragedies on the web (including the above story) include the statement: “We’ve done this event safely for many years without incident . . . ” Such statements are little solace to the family or families ultimately affected by a tragedy.
Reference, in another story, a statement by an Outward Bound spokesman in response to questions regarding the 2006 death by heatstroke of one of its participants: “In the past 25 years, the company has put thousands of kids through the Utah desert, and none of them have died. Everything done that day was in keeping with Outward Bound’s standard safety protocols.”
Yet, again, despite the unstated “standard safety protocols” being followed, as in the Boundary Waters story, someone tragically died (in the desert . . . in extreme heat . . . of heatstroke ). And, while the odds were small over the span of those 25 years that someone would tragically die, those odds became large for the one that did, and again, are of no solace to the affected family.
Indeed, the above two “we were following protocol” statements are, sadly, so at odds with the tragic end results that, to make such statements, is nearly an admission that the protocols were either inherently defective, or the accompanying judgment that was exercised was fatally flawed.
Admittedly, tragedies sometimes occur despite “following protocol” that could not have been foreseen, or could not have been reasonably prevented, such as one brought on by the actions of a third party, or an unexpected medical issue unrelated to the activity.
This assumes, of course, that the protocol is not inherently flawed, such that it might not take into account, or provide for the taking into account of, the possible existence of variable or unpredictable factors (gear, people, environment ) that might render the protocol useless as a barrier to tragedy, such that, as shown by the above stories: (1) a participant could drown while wearing two PFDs, or (2) die of heatstroke in the extreme heat of a desert while participating in a supervised program.
The takeaway is that following a set protocol is not a substitute for the exercise of good judgment with respect to any situation which presents significant risk, particularly if the extent of risk for a specific situation is not constant, but may vary with time, and may render the believed protective effect of the protocol less effective than initially thought to be.
Particularly if youth are involved!
Protocols are important to have in place to provide a basic framework for groups operating in an outdoor environment, but at some point, those in a supervisory capacity will need to exercise judgment to confirm that following the established protocol is consistent with the conditions encountered, or to be encountered, and make the decision whether the activity should proceed, be modified in view of the conditions, or avoided.
This discussion has relevance to adult volunteers who follow BSA policies and guidelines (protocols) such as Safety Afloat, Safe Swim Defense, Trek Safely, among others, and who hopefully, practice such policies and guidelines together with a healthy dose of good judgment on the part of the adult volunteers.
As noted in the Guide to Safe Scouting, 2018, p. 6:
“Every possible contingency will not be covered with a hard and fast rule, and rules are poor substitutes for experience. Ultimately, each responsible adult leader must personally decide if he or she understands the risk factors associated with the activity, and is sufficiently experienced and well-informed to make the rational decisions expected of a ‘qualified supervisor‘”.
The current version of the Guide to Safe Scouting similarly states:
“In situations not specifically covered in this guide, activity planners should evaluate the risk or potential risk of harm, and respond with action plans based on common sense, community standards, the Scout motto, and safety policies and practices commonly prescribed for the activity by experienced providers and practitioners.
Perhaps this quote by Sir Robert Baden-Powell from his 1914 book Quick Training for War is appropriate to include here: ‘… The books lay down definite principles and examples which serve to guide the leaders when applying their common sense to the situation before them. No two situations are ever precisely the same, and it is therefore impossible to lay down exact rules that should guide in every case, but a man who carries precedents and principles in his head has no difficulty in applying their teaching in supreme moments of sudden emergency …’ ”
Remember – KNOW the protocol! But – EXERCISE appropriate judgment!