When it all goes wrong

[EEL]

In the February 2013 Sea Kayakers there is a article by Sean Morley about the near disaster at the 2011 Lumpy Waters Symposium. Many good things presented to think about. To me the description of the two groups as large when the contained 8 paddlers each and there were two coach/instructors per group is sobering given the size of many club paddles. The problems began when Sean was last off the beach and without immedaite direction the students failed to follow instructions from beach briefing and blindly paddled in harm's way; sound familiar? If you think you have great skills, then think of Sean, who is recognized as no slouch, sans boat and paddle needing to get things right and rescue others.

Ed Lawson

[Brian Nystrom]

Based on experiences I had with the club, including being involved with the original "trip leader training" program, I'm of the opinion that there should never be less than two qualified leaders/guides in any group and that a ratio of 3:1 participants:leaders is about the safe limit. Beyond that, things can get out of control very easily. It's amazing how much of a burden a single paddler who's sick, injured or incompetent to paddle in the prevailing conditions can become to a group, especially if towing and supporting the paddler is involved. If you have multiple issues at the same time, an inconvenient situation can turn dangerous in a heartbeat. I've experienced that firsthand on what should have been a pretty benign trip where 6 of the 8 of us were trained trip leaders. We handled it, but if one more thing had gone wrong, we'd have been calling the Coast Guard.

I guess the bottom line is that the lower the skill level of the participants on a trip, the higher the number of leaders/guides needs to be. That's why I cringe when I hear of a single guide taking 5 or more beginners out on trips. All it takes is an unexpected change in conditions (such as a thunderstorm) and even a relatively flat water trip can go completely out of control.

[PeterB]

Mr. Nystrom's is , as usual, the voice of reason here.

Yes, sorting out the ratios of experienced to less experienced paddlers on any given trip , and matching up these human resources to the float plan, is a big part of what trip planning is all about. One thing one notices on sound trips is that the makeup of the group is considered in advance and/or matched to the float plan of that given day. On lower level trips, or trips where there is a range of paddler experience, this means arranging for paddlers to be along "on safety."

Another thing one notices in incident reports is how often the ebb is involved. When things go wrong on the ebb, paddlers are often carried away from, not towards , areas of safety. also, the chance of outgoing tide meeting incoming wind waves or swell is much greater.

When in question, one big thing that can be done is plan a trip on the flood rather than the ebb. This may of course , mean not enjoying the features of a given venue, but prudent nevertheless. E.G. Fishers Sound has tidal features on both the ebb and the flood . The tidal races on the ebb are legendary but there are also good conditions on the flood, so a prudent plan - something you can bet Rick and Greg's people consider when planning their Fishers Race events, would be to take groups to tidal features only on the flood.

[...]

Peter, I really enjoyed reading about your understanding of the risks associated with moving water during an ebb versus a flood. We can all apply that knowledge to the Western Rivers in Maine as well as our practice sessions under the Seabrook bridge. It does touch upon a larger topic of learning to understand the sea state in which we plan to paddle and how we determine risks.

Brian, I very much enjoyed reading your guidance concerning the ratio of leaders/guides to participants. Sometimes it seems as though a trip is planned and we all hope to sort things out on the water based upon who participates in the paddle.

You both did touch upon a much larger topic of what are the core competencies of someone who plans and executes safe trips. It seems to me, we spend a great deal of time learning how to pick up the pieces after disaster strikes. However, I would like to believe that with solid trip planning and safe on water execution, we can avoid most disasters. Perhaps the key is in acquiring the core competencies without having to learn them the hard way.

I would greatly value an understanding of the core competencies we, as a community of paddlers, value in trip leaders who plan and execute safe trips.

Warren

[JohnHuth]

I couldn't find the Sea Kayaker article online, but did find this blog about the incident:

http://blog.redalderranch.com/?p=89

Interesting reading. I don't have a lot to add, but one thing that struck me is that the blogger admits to strong misgivings just at the start. I wonder whether the group mentality and the scheduling of the event overrode the instincts that said "this isn't safe". When I solo paddle, every so often I'll find conditions that are too extreme, and I've gotten into the habit of saying "oh, well....guess I'll wait until another day" - a lot easier when it's just me. When I get back home, my wife will ask "back so soon?". I'll answer, "yup, conditions were too hairy," and she'll nod knowingly.

[...]

John,

Now I am really curious! Being that you are an analytical person, how much of your decision to paddle is based on prior experience. The gut reaction versus the careful analysis of the variables. This past season I purposely paddled in waters that were new to me in an effort to avoid being influenced by prior experience. It forced me to "learn to observe" versus "I know what will happen here". I suspect you do the same.

Therefore, a key core competency for any trip leader might be a keen ability to observe the sea state. Would you agree?

Warren

[Gcosloy]

What struck me was the contrast between the Blogger's reticence in mentioning his strong misgivings about the site choice and his admirable tenacity and perseverance during the 2 hour rescue phase. Maybe its a generational thing but there seems to be more of a nod to politeness and not ruffling feathers over demands to discuss safety. I agree with John when he wrote: " I wonder whether the group mentality and the scheduling of the event overrode the instincts that said "this isn't safe". Maybe one of the things we need to do during beach discussions of planning before trips is to encourage the outliers and dissenters to speak up.

As an aside, many of these SK rescue stories either have large groups or are led by competent instructors. Statistically, speaking do we know what is the ideal group size for safe paddling all other things being equal?

[JohnHuth]

Warren -

Well, for me, it's not only the observation of the sea state, but it's also some prediction of the sea state in the future, based on wind speed forecasts, fetch, and also the bathymetry, associated with the timing of the tide. Add in current, and there are a lot of factors to consider.

So, the sea state may be acceptable to perhaps a bit hairy at some moment, but I know that the wind will pick up over a long fetch as the day wears on. I'll approach a river's mouth on an ebb tide, and there are shoals around the mouth which cause the waves to steepen up. Then, I wonder "can I paddle out to sea to avoid the breakers on the shoals in case it gets really bad?" Or, it may look good in a sheltered area, but on a windward shore, you could predict that things kick up.

I *do* like the idea of trying to "read" a new coastline, as you suggest.

There's an additional factor, which is skill level. Even for myself, I feel that early in the season I have to work on things to re-develop timing, instincts and the right muscles. I had this happen to me this last year - I was on sabbatical in Geneva, Switzerland, working on the Higgs boson discovery and also working on my book. I was pretty much desk-bound until August. When I went out on a paddle, I knew that I'd readily go into the conditions I saw after some tune up, but the tide was receding over some shoals I knew of in the distance, and I could predict what it would be like. I paddled closer to the shoal. Normally I would've gone through it, but I hadn't gone through my usual conditioning period, so I turned back.

The last bit is important to consider, I think. Not only do you have to consider experience of people you're with as gauged against conditions, but also the current state of readiness. If they're rusty, their rolls may not be working the way they used to, or the instinct of bracing is not as fine tuned as it used to be.

John

[...]

John,

I am pleased to hear that you carefully observe the sea state. I am also pleased to hear another key core competency. The ability to understand weather or more specifically to understand changing weather patterns and their affect on the sea state. It is said that we must always observe "future waters" in an effort to make adjustment in our course. I like to think we must constantly look up at the sky as well to observe "future weather" and adjust our course.

John, you also touched upon what many would say is our greatest risk. It is who we choose to paddle with on each trip. I, for one, do not wish to paddle solo. Therefore, I need to be able to observe the current state of my fellow paddlers as well as I observe the sea state. Some days that is not an easy task especially if they are hesitant to share their thoughts and concerns. Interestingly, for me it is the beginner/novice paddler that communicates the clearest if you are ready to receive the messages. Perhaps, that is another trip leader core competency. The ability to receive and understand a message of concern.

Warren

[rfolster]

To me the description of the two groups as large when the contained 8 paddlers each and there were two coach/instructors per group is sobering given the size of many club paddles.

Ed, I think that when you have an instructor/student situation in a high-risk venue like tide race surfing, a 3:1 student/instructor ratio is probably too high. For the club paddles, we do not have instructor/student arrangements, even if "coaching" occurs. Most club paddles are also not taken into such high-risk venues.

However, I think that there are many aspects of this incident that can be directly incorporated into the club. Both senior instructors and one of the two assistant instructors had never been to this location before. While this in itself is not a problem, there approach to the conditions was absolutely incorrect. Sean had tried to take the time to study the conditions from the shore, but was feeling rushed to gear up and get out there. There should have been a MANDETORY beach briefing where all 16 individuals stood and WATCHED the conditions and discussed where they would go, how they would stick together, and what they should do if there were any problems. At that point, they could have re-evaluated their intentions and changed the itinerary for the day.

Actually, as I think more about it, how were they even providing instruction to the students in such conditions? It would seem to me that a better form of instruction would be to keep one class on the spit of land while the other class surfs. The instructors on land could discuss what is going on, and point out the correct and incorrect performances on the water. They could then switch groups to allow everyone time on the water practicing and time on land learning.

Getting back to how this relates to our club paddles, Gene said "Maybe one of the things we need to do during beach discussions or planning before trips is to encourage the outliers and dissenters to speak up." I think that it is unfortunate to portray anyone as an "outlier" or "dissenter", when we should all just be "fellow paddlers", but it is too often true. Although I may have officially lost my status as a "newbie" this year, I know that I still have a vast amount to learn, and it can only be done by having DISCUSSIONS before, during, and after trips. Unlike popular belief, this does not mean that everyone has to agree all the time. We all need to recognize that we each have something to contribute to the conversation, and that compromises will ALWAYS have to be made. It is up to us as individuals to decided how much we are willing to compromise for the sake of the group, and whether or not those compromises are too much for us to participate. That is the basis for the CAM model that we operate under.

[...]

Rob,

I know you, more than most, put a lot of thought and effort into successful CAM model experiences.

I will admit my past experiences with CAM have been inconsistent. Our Sebascodegan Island trips as well as the trip to Muscongus Bay and Jonesport were great and those were classic CAM trips. For me, some other trips have not been so great. Personally, I have much better success with CAM when the number of participants is four or less. It seems to me each member of a smaller group is more invested in the success of the trip. In some larger groups, I have observed other members having the tendency to be "followers" and rely on others to plan and protect them. I believe, however, the success of the CAM methodolgy is related not to the size of the group as much as how invested each member is to the success of the effort? If so, how do trip leaders successfully engage each member? The beach briefing may not be the best method.

This coming year I want to experiment with trips of 6 to 8 paddlers using the CAM methodogy and see if it is possible to have each member fully engaged in all aspects of the trip. A successful CAM trip of 8 participants would prove to me the methodolgy is unrelated to group size.

Warren

[eneumeier]

Without regard to the sport or activity, one very common factor in things "going wrong" is that people who had misgivings did not speak up. The NY Times just published a fabulous article in the Magazine on the tunnel creel (Stevens Pass) avalanche that killed 3 expert skiers on Feb. 12. (I was in Seattle at the time, heading to Whistler with my sister. The road to Stevens pass was still blocked.) Several of the people in the group had misgivings about the plan but said nothing. These were some of the top extreme skiers in the world. If you have access, do check out the online, interactive version. It is very well done.

http://www.nytimes.com/projects/2012/snow-fall/#/?part=tunnel-creek

When we did trip leader training we covered this: How do you make people comfortable with speaking up, even for little things like foot pegs being uneven. That can lead to a cramp or make paddling inefficient and cause fatigue. I got in the habit of doing a bit of whining myself, to model this behavior: "Does anyone mind if we stop for a minute, I need to stretch." Often others needed a break for various reasons and were glad to have one. If someone was embarrassed about needing a tow, I would tell some of my being towed stories. Etc.

I think the best thing to do is to establish a culture of speaking up and reinforcing it. If someone has a question, thank them for asking. Praise them for sharing it with the group. Never criticize someone who wants to stop or question a plan.

On the water, when it all goes wrong things can spiral fast.

Happy New Year!

Liz

[PeterB]

I believe, however, the success of the CAM methodolgy is related not to the size of the group as much as how invested each member is to the success of the effort? If so, how do trip leaders successfully engage each member? The beach briefing may not be the best method.

This coming year I want to experiment with trips of 6 to 8 paddlers using the CAM methodogy and see if it is possible to have each member fully engaged in all aspects of the trip. A successful CAM trip of 8 participants would prove to me the methodolgy is unrelated to group size.

Warren

CAM methodology is most definitely related to the size of the group. As group size increases, paddling under the CAM model becomes more difficult.

This is from the CAM literature:

"Q.Do trip sizes need to be small?

Yes. If you look at the model, participation and cooperation are important aspects of it. As the trip size increases, it becomes less and less practical for the group to work as a team. Everything increases in difficulty: planning, organizing, and shared decision making. When a group grows to critical mass, common adventure becomes impractical."

We covered this in the the CAM training sessions, and have sort of fixed on that "critical mass" being around 8 ; thats a group size over which one should be prepared to encounter problems.

Naturally, this is not a fixed or dogmatic formula: some larger groups may work just fine, others will not, as it depends on the participants, the conditions , the float plan; the typical blizzard of variables. Point is, in general, one ought to see burgeoning group size as a danger flag and be prepared to respond to it. One option is to break a group into smaller pods, something which is done with some frequency. E.g. In planning the Solstice paddle, we try to have experienced paddlers on each trip , so the group may be prepared to break into smaller pods.

[Gcosloy]

Without regard to the sport or activity, one very common factor in things "going wrong" is that people who had misgivings did not speak up. The NY Times just published a fabulous article in the Magazine on the tunnel creel (Stevens Pass) avalanche that killed 3 expert skiers on Feb. 12. (I was in Seattle at the time, heading to Whistler with my sister. The road to Stevens pass was still blocked.) Several of the people in the group had misgivings about the plan but said nothing. These were some of the top extreme skiers in the world. If you have access, do check out the online, interactive version. It is very well done.

http://www.nytimes.com/projects/2012/snow-fall/#/?part=tunnel-creek

When we did trip leader training we covered this: How do you make people comfortable with speaking up, even for little things like foot pegs being uneven. That can lead to a cramp or make paddling inefficient and cause fatigue. I got in the habit of doing a bit of whining myself, to model this behavior: "Does anyone mind if we stop for a minute, I need to stretch." Often others needed a break for various reasons and were glad to have one. If someone was embarrassed about needing a tow, I would tell some of my being towed stories. Etc.

I think the best thing to do is to establish a culture of speaking up and reinforcing it. If someone has a question, thank them for asking. Praise them for sharing it with the group. Never criticize someone who wants to stop or question a plan.

On the water, when it all goes wrong things can spiral fast.

Happy New Year!

Liz

Well said Liz. Do you think there may be a correlation between not voicing concern and perceived expertise. Its the experts among us that should know better and yet anecdotes seem to indicate this?

[...]

Peter,

Thank you for the info concerning the maximum recommended size for a CAM trip. That explains a lot! My memory of a CAM trip with 11 paddlers was very similar to what you might encounter in herding cats. The very loose structure really fell apart when a rock garden came into view. More than half the group took off like hungry dogs chasing a meat wagon. It struck me at the time that there must be a better way to do this. Now I understand.

Warren

[eneumeier]

In the avalanche, one of the experts pulled her "balloon" cord to inflate two bladders (new avalanche safety technology). Her first thought on doing so was that the others would probably laugh at her, but that action likely saved her life. So, yes, experts can be reluctant to speak and act for safety.

But, for NSPN purposes I think the problem is more that trip initiators have a bias toward wanting to start or complete the trip (and that bias needs to be checked) and other participants need to be comfortable speaking up (and not be worried that "I didn't want to hold up the group"). Club trips do not start out in extreme or even particularly hazardous conditions.

Liz

[Pintail]

<...pleased that you carefully observe the sea state...>

Warren, I think you may be fixating too much on what seem like details -- surely <everyone> takes <some> time, however minimal, to look at conditions and assess them? Be that as it may, I suspect that what we all need to think about more is "risk assessment" and "incident/risk management". We used to talk about these subjects years ago when we trained leaders -- perhaps it is time we had one or two workshops on these subjects (they really are two). We have <several> well-qualified characters among our number who are well-suited to hosting such classes and doubtless would be happy to do so -- we could even pay for a professional "risk assessor" to come and talk to us, if we deem it a good idea?

What Elizabeth and Brian Nystrom wrote above is very sound indeed and since we have adopted the CAM model of operation, maybe (just maybe) we need to start going back to basics to reinforce our individual and combined understanding of things like -- risk?

Warren, don't totally and categorically deny yourself the pleasure that is often to be had of paddling solo -- simply make sure of your skills and then practise them (and practise them some more), so that you <can> rely on yourself. Sound risk assessment will then hold you in check, if need be, when you are imitating Kate, say, on a solo adventure somewhere up the coast!

[...]

Liz,

I really like your statement, "Club trips do not start out in extreme or even particularly hazardous conditions". It seems to me some groups are not as attentive to changes that can occur AFTER the trip is initiated.

For me the grand "Ah Ha" moment this past season was when I realizing that a weather forecast is good for less than 4 hours. A camping trip off the coast of Maine started out with fine weather, but all that changed even though the original forecast made no mention of the potential for changing conditions. I have always understood the rapid way in which a thunder and lightning storm can arrive, but this was very different. The wind speed and direction changed in a most dramatic manner. If I had not been "glued" to my weather apps, we would have lost our window of opportunity to safely evacuate. Although to the group the trip simply underwent a minor modification, but I knew better and welcomed the new knowledge. I now look at the weather in a whole new way.

Warren

[...]

Christopher,

Yes, I would very much enjoy attending a workshop on risk assessment skills. I would like to believe we are all better off if we fine tune our skills in learning to avoid a disaster rather than focus all our energies learning how to put all the pieces back together. For me, I could perform risk assessments constantly while I paddle. Speaking for myself, putting the pieces back together is not very easy to simulate and practice often enough for me to be really good at it.

Warren

[JohnHuth]

Two items come to mind - isolated thunderstorms in the summer can be very local and unpredictable. Rather than relying on ap's, I'd recommend becoming familiar with their pattern of development. Frequently the wind starts out of the E or SE and there are growing vertical cumulus clouds to the west. When the storm is close, the wind "veers" to the S, then SW and you have to deal with strong downdrafts, which can be really hairy. Having someone in the group with a good 'weather eye' is probably a good idea - that is to say - someone volunteers or is designated to keep an eye out for changing conditions.

In terms of the 'squeaky wheel' phenomenon - it's amazing how one person can turn the dynamic around from wallowing into a dangerous situation to keeping things safe. I was hiking up in the Rockies with a bunch of fellow physicists. These guys were a bit crazy, and at some point, I found myself leading and cutting steps into a steep icy slope with an ice-axe. We got to a spot where to go on we'd have to cross a knife edge ridge with very steep icy slopes on either side dropping precipitously 3000 feet down on both sides. They were all ready to cross, and I said "no way, no how am I crossing that without protection..." I think about five of the other guys in the party sighed a breath of relief - sort of like saying the emperor has no clothes. Two guys did do the crossing, but didn't have an accident. A week later, one of the guys who did the crossing came to me and said "You know, you made the right decision in not crossing that ridge...I never should have done that." And I was just one lone voice, and spoke to my misgivings. It's an important thing.

[EEL]

Random if not off topic thoughts.

It is a puzzle to me why the CAM trip model somehow becomes a topic if not focus on threads such as these. Many of the fundamental issues involved in safe travel on the sea are there for all of us to deal with no matter whether we are paddling solo or in any group regardless of organization. True, the details and approaches change, but still this frequent focus on the CAM trip model is a wonderment to me.

I find it intriguing how we all have developed a reliance upon on devices to inform us of what is happening around us. I suspect John Huth would suggest looking at the sky is a very powerful technique for understanding the weather we will experience and our personal observations will more often than not provide accurate short term predictions for where we are.

I totally agree spending time developing the skills to pick up the pieces, to the extent it is possible, but not spending the time to develop the skills to avoid an incident is misguided.

Ed Lawson

[PeterB]

Warren,

Developing risk assesent skills and learning how to "pick up the pieces":

(incident management, or "disaster management " as you see it) It's not an either- or thing. We develop risk assessment skills and we develop incident management skills . I can't say whether one is more important than the other but no point in doing so: they're not mutually exclusive and definitely all part of the alphabet soup of general development as a paddler. And these are all covered in the NSPN CAM workships, perhaps not to the satisfaction of our members but .. A work in progress.

[...]

John,

Thank you for the info on how to anticipate a potential thunderstorm! I really do like the idea of checking the sky on a routine basis when it is possible to do so.

Interestingly, the most challenging situation for me regarding the weather this past season happen at night when my ability to see the sky clearly was hampered by darkness. I checked my apps at 11:00PM and again at 3:00AM when all I could detect physically was the wind speed and direction. Clearly, that night the apps helped fill in the blanks.

I guess it really is all about developing a "safety web" of systems and processes to help keep us all safe.

Warren

[rfolster]

Over this past year, I have seen a lot of CAM bashing by many people who (in my humble opinion) don't really know how CAM is supposed to work. Then an incident report will come out, and there is all this talk about "should have this" and "could have that", much of which falls into the parameters of the CAM system. One of the most important, and most overlooked, is the idea that every participant should be a leader at some point of the trip. Whether it be that each person takes a turn at navigating from one point to another along the journey, or some other means of being a leader of the group. If we encourage that more, and don't let people be "sheep" following the herd on club paddles, they will HAVE to be more vested in the nature of the trip.

Chris, I like your idea of the "risk assessment" and "incident/risk management" clinics, but I believe that these topics ARE actually covered in the CAM clinics. Last year we all practiced planning our own trips, taking weather and location into account, and discussed what the variables are and what dangers could present themselves. They also include information on how to be a "leader" on any trip you participate on. I would like to see a large turnout this April when Scott holds the next CAM workshops. Maybe if we get some of the long-time NSPNers in there to be reminded of what CAM is all about and how we can make sure it is utilized on club paddles, then maybe we can put an end to those trips that "fall apart" when different interests pull at the group.

[PeterB]

Robert,

I'm glad you have pointed out what the CAM sessions actually offer. Also, your comments touch on that CAM concept that "leadership is fluid"; meaning that there need not be one set leader for the entire trip. I do not think, however ,that "every participant should be a leader at some point during the trip" . There may well be participants who either do not want to be, do not feel comfortable being, or just shouldn't be, leading a group, and this is perfectly fine. The point is, CAM is a model intended to draw on the assets/ human resources of the entire group, such as they are.

So, if , say, there were a trip and some sort of incident occurred, (e.g. a simple capsize and swim up to a more complicated scenario like two capsizes in moving water, swimmers drifting away from the group) the trip participant with the most rescues/incident management experience would naturally assume leadership during this scenario, but could well slip back into a previous role for the rest of the trip, once the incident was sorted out.

If, on one of your camping trips, one person excels at planning/navigation but another is the "go- to" person for launching and landing a group on/ off a beach, or cooking, whatever, then... this is CAM to the letter.

That said, it certainly admirable goal for different participants to take turns leading a group , but this is not a necessity, only appropriate as the situation dictates. .

Also, your comments on the value of beach briefings are well -taken : : as has been said by many here, the beach briefing is important : it falls into that

" avoidance . awareness" area ( the "A" in C.L.A.P ) ; anticipating problems and hazards before they arise.

So, in Warrens scenario (half the group goes rock gardening and the other half doesn't) problems arising from this could be avoided in the beach briefing: with a simple meet & greet, where each person quickly reviews her expectations for the day (a pretty standard part of beach briefings) the group may launch knowing in advance that half the group may want to split from the other half if rock gardening presents itself, , and be better equipped to deal with this eventuality.