Most
of my sea kayaking is solo these days. I’ve strangely come to
enjoy it because the tempo is entirely my own. Following the
requisite jug of coffee, I trolley my kayak down to the beach and
head out to sea in the early morning. Some days, the ocean is
steaming because the sea is warmer than the air. Frequently, the bay
is full of fish and dolphins and occasionally seals, always
cormorants. If the wind is coming from the south, I go south, if
from the north, I go north, very infrequently, maybe once a year, I
go west, although I have seven kilometres of ocean paddling before I
get to the bridge over the Clyde River and the start of the truly
sheltered water paddling.
By yourself, you get a lot of time to think and I think more
carefully about ducking through slots and gauntlets, but I still do,
I just watch the timing and conditions because it’s winter and cool
on the water and even cooler if you are wet. The only time I’ve ever capsized in one of these slots was in winter and
resulted in me always carrying a spare set of paddling clothes in a
dry bag during the winter. I rarely stop, mostly paddling on at a
steady pace, sometimes doing some sprint training, until I reach my
minimum paddle distance (20 kilometres in winter), although sometimes
I will go further.
Yesterday, I did 24 kilometres, down to Jimmies Island, through
the gap between the island and the mainland and back home. As I
often do, my outward journey followed the coast into all the little
bays but coming back north, it was a straighter line. Strangely, I
found myself thinking about an incident that happened in June 2011, a year before Doug and I left Nelson, BC for Australia.
Here is the story (long) of that incident which happened while I was
a member of the SAR unit at the centre of the incident. It was only
after leaving Nelson that I had any real idea what happened as the
SAR members involved kept the details private until they had to
testify over a year later in the Coroners court.
To my knowledge, SS, is the only non-professional to have been
killed during a Search and Rescue (SAR) mission in British Columbia.
There have been other fatalities but, crazily enough, these
fatalities occurred during training exercises. Given that I think
getting injured while training in the gym is wrong-headed, getting
killed while on a training exercise is a true tragedy.
SS died in a “rescue” gone wrong on the (at the time) flooding
Goat River in the east Kootenays. Although I was a SAR team member
at the time, I did not go on this call out. For a start, I had
sprained my ankle the previous day walking off an 8 pitch rock route (Megawatts) near
Castlegar and was sitting at home with my leg elevated. However,
even if able-bodied, I would not have been on the call because the
“mutual aid” was for the swiftwater rescue team and I was not on
the swiftwater team. I had been asked but declined because it had
been a half dozen years since I had done any significant whitewater
kayaking and I, naive to the ways of SAR, thought that members of the
swiftwater team should have swiftwater experience. Similarly, I
thought members of the rope team (which I was on) should be climbers,
although I was the only active climber on the rope team at that time.
I did a bit of whitewater kayaking back in the day. I ran a few
rivers in Australia, and used to spend summer afternoons paddling on
the whitewater course on the Bow River in Kananaskis Country. I was
never very good, and never got a solid roll, but I did manage to get
down the grade three rapids upright. In 2019, I followed Wildey (as
faithfully as I could) down the Snowy River from Willis to Buchan and managed to limit my bail-out and swims to three, but I portaged a couple of the harder rapids.
Whitewater or swiftwater - whatever you call it - moves fast with a
tremendous amount of power. Much like surfing a sea kayak, you
cannot fight a breaking wave and you can’t fight a fast moving
river, you have to work with the power of the water. A moments
inattention and the kayak is upside down.
Back in 2011, it seemed to me that anyone joining the swiftwater
team should have a deep understanding, preferably gained over years
of running whitewater rivers, of river hydraulics because things
happen fast on whitewater rivers. A mere second of leaning the kayak
the wrong way on swiftwater and you’ll be upside down. It’s the
same principal as riding a breaking wave into shore, you have to lean
such that the moving water holds the kayak up rather than flipping
the boat over. The lean has to be instinctual. In any fast moving
situation you must react rapidly and instinctively because by the
time your brain runs through the logic of the manoeuvre it’s too
late. Whitewater kayaking, kayak surfing, these are skills you have
to learn by doing. Watching videos, reading books, even training
under controlled circumstances does not imbue the paddler with the
instinctive skills to react correctly and quickly.
What happened to SS is the ultimate boiled frog phenomenon whereby
the risk of the mission
gradually increased until the additive effect of multiple errors
added up to equal tragedy. Backcountry skiers in avalanche terrain
know this all too well. The skiing is so good that the group keeps
pushing into riskier and riskier terrain, propelled forward by a lack
of negative feedback until one or more skiers ventures over the
convex roll, out onto a wind slab, or down a loaded gully and an
avalanche results. The situation is so classic that it is amazing
that humans continue to repeat it.
Here’s what happened briefly.
Two SAR units from two different jurisdictions responded to
reports of a vehicle submerged in the Goat River. There were 21
people in all, 11 of whom had some swiftwater training.
The Site Leader was the owner and operator of a company which
provided swiftwater training to various SAR units including one of
the responding SAR units.
SAR units have a fairly rigid chain of command but Site
Leaders may consider input from team members when planning
the mission. The word “may” is doing some heavy lifting here
because a lowly GSAR team member is unlikely to be heard by the
higher ups even if their experience is relevant.
The Goat River was in flood and the vehicle was in a
particularly deep pocket of water. The RCMP (Royal Canadian Mounted
Police) Dive Team refused to assist in the mission as they deemed
the conditions too dangerous due to deep, cold, murky, fast flowing
water and the possibility of the vehicle shifting in strong
currents.
A woman had gone missing some days earlier but there was NO
evidence that the woman was in the vehicle and NO chance that this
would be a live recovery even if someone was in the vehicle. The
body of the missing woman was subsequently located down river some
days later by an RCMP helicopter crew.
A tension diagonal was rigged across the river (two ropes had
to be tied together as the river was so wide at the time) and
another two tag lines were attached to the Cataraft to enable the
Cataraft to be manoeuvred into position. A second Cataraft was
positioned downstream as a rescue boat. This is a pretty standard
swiftwater rescue technique but the teams in the Catarafts should be
prepared and capable to self rescue if required. In this instance,
that means you can cut the lines and pilot the Cataraft down a
flooded river safely.
Two people would operate the rescue Cataraft. SS who was
designated Team Leader for the Cataraft and another team member (who
had never operated a Cataraft). SS wore a helmet mounted camera as
the mission was being filmed for a TV series. Other cameras were
filming the mission from the shore.
SS and the team member entered the Cataraft and, with much
difficulty, the Cataraft was finally moved to a position above the
submerged vehicle. Due to the force of the water, this took
multiple attempts and it was not possible to use a pole mounted
waterproof camera as planned to look inside the vehicle due to the
force of the water.
A tow truck was brought to the scene and the various pieces
of steel towing equipment were provided to the Cataraft crew
including a chain, a J hook with chain attached, several shackles
and a 15 metre coil of wire cable. 15 metres is 50 feet, the length
of my sea kayak tow. That is a lot of cable to keep organised on a
Cataraft.
The Cataraft, now equipped with the chain and wire cable,
(placed on the floor of the Cataraft) was again positioned above the
vehicle. An attempt was made to attach the chain to the vehicle but
due to the current and water depth this was not possible.
The Cataraft returned to shore and the chain was replaced
with a J hook attached to a chain along with the wire cable which
remained on the floor of the Cataraft.
The Cataraft and two team members were positioned again above
the vehicle and this time the J hook with chain attached was
successfully attached to the vehicle by the crew member.
The crew member held onto the chain attached to the J hook
which was hooked to the submerged vehicle while SS began to uncoil
the steel cable preparatory to attaching it via shackle to the chain
and J hook. It is unclear from the Coroners report whether or not
the cable was ever attached to the J hook and chain. Regardless, in
essence, the Cataraft was now attached to the submerged vehicle via
the crew member.
The Cataraft shifted and turned sideways to the current
likely in response to being effectively tethered at the rear to a
submerged object in fast moving water.
Immediately the Cataraft turned perpendicular to the current
it began to sink. This is because the force of the water flowing
downstream piles up on the baffle of the Cataraft and drives it
under water. Once this process has begun it is extremely difficult
if not impossible to reverse.
The tension diagonal was now under extreme load and
subsequently broke which sped up the sinking of the Cataraft.
The cable became wrapped around SS’s leg and she was pulled
from the Cataraft as it began to sink. The team member attempted to
hold onto SS but the force of the water was irresistible and he was
forced to let go.
SS managed to hold onto the ropes of the sinking Cataraft for
a time but was eventually unable to hold on any longer and was
dragged downstream by the current but remained tethered by her
entrapped leg to the vehicle. SS subsequently drowned.
Attempts were made to effect a rescue but the force of the
current rendered this impossible. Neither of the Catarafts were
able to reach SS, throw ropes did not reach her (not that a throw
rope would have helped anyway), and the one team member who
attempted to swim out to SS was carried downriver by the current.
SS was retrieved the following day by which time the water
level had dropped so much that the rescue team could basically walk
across the river. The vehicle (empty) was recovered at the same
time.
So many things went wrong and so many signs were ignored as the
teams gradually escalated the risk of the mission until the ultimate
catastrophe shut the entire exercise down. I remember at the time
that the primary emotion I felt was anger, not sadness. So many
people’s lives risked for nothing and this was evident from the
very outset. The first rule of SAR is do not endanger the rescuers,
and yet, 21 people under the command of a long time SAR member, got
involved in a highly technical rescue in a very fast flowing river
with no potential for a live recovery even though water levels in the
river were predicted to drop significantly over the coming days.
There was ample opportunity over the course of the mission to
pause, take stock and call the entire mission off until the water
levels had subsided (which they did very rapidly). The exercise
proceeded over many hours with the Cataraft returning to the river
bank multiple times. Each time the Cataraft went out and returned
the Site Manager and the team members were gathering more and more
information about how challenging it was to operate with the river in
flood. One team member on the Cataraft had never operated a Cataraft
and the Team Leader (SS) on the Cataraft while confident (?over
confident) was inexperienced in this type of mission. It’s
impossible to know in retrospect, revisionist history is real, but it
appears that the information gleaned from repeated deployments of the
Cataraft was never integrated into the overall risk mitigation
strategy (if there was a risk mitigation strategy). Put simply,
personnel did not appear to understand the feedback that the river
conditions were providing.
The Site Manager and other personnel, including the investigator
from Work Safe BC, concluded that filming the incident for a
television broadcast did not influence the decisions made on site,
but I think anyone with a skerrick of knowledge about human behaviour
knows that the “kodak” effect is real. There is very little
drama to be had from a SAR crew arriving at a search scene then
turning around and driving back home because the conditions are too
unstable and too uncontrollable for reasonable management of risk.
There were four other major confounders to the accident which are
impossible to “prove” in a Coroners court (which is not designed
to assign blame) but which are present in virtually every outdoor
accident that occurs. The first is that each previous decision
influenced the next decision downstream. Once a decision was made to
rig the tension traverse and deploy the Cataraft, the possibility of
calling the entire mission off became more and more difficult. Each
step forward, which in this case was each launch and re-positioning
of the Cataraft, psychologically drove the team further and further
down the tunnel of continuing the mission until the ultimate end. In
reality, options are not necessarily limited by previous decisions,
but, the foibles of the human mind make it very difficult once we
have made a series of decisions to recognize that there are still a
multitude of different options available, including turning back or
aborting the entire mission.
I used to see this when travelling the backcountry with ski and
climbing buddies. If we made a route decision mistake, it was
incredibly
difficult to pull the group back and reverse course to get back
onto the right route. People would justify all kinds of crazy
decisions to avoid turning around and route options often veered into
the outright lunatic.
The second confounder is personality and (over) confidence. There are some people, we all know them, and I knew
the people involved in this incident, whose confidence in their
ability far outstrips their actual ability. These are the folks that
seem to make the same or similar errors of judgement again and again
and yet never take a step backwards and assess their ability fairly.
If you are like me, you eventually start avoiding trips with these
folks because they are incidents looking for a place to happen. Over
confidence and hubris makes reasonable feed back impossible.
The third confounder is very closely linked to what a mate of mine
used to call “agendas.”
Most people on a SAR mission or an outdoor adventure trip are out
there to achieve the goal and go home safely, but some people, almost
always the over-confident, have agendas. These are the folks that
make trip management and SAR missions difficult because, although
they are ostensibly there to work as a team member to meet a goal,
they are really there to prove themselves the strongest, the fittest,
the most competent, the hero of the day. I’ve done dozens of trips
with these folks and the challenge is to enable them to feel as if
they’ve met their agenda while maintaining group safety and
enjoyment. The entire day revolves around group management and it’s
a skilled operator indeed who can run the mission or the adventure
without an unexpected incident when there are hidden agendas
involved. If the lead operator is the person with the agenda,
reasonable and rational decisions become impossible.
The fourth confounder is situational awareness or lack thereof. The only way to develop situational
awareness is by experience yet experience itself is inadequate to
achieve high levels of situational awareness. It is very difficult
to develop situational awareness if the environments (which includes people, places,
weather, etc.) under which the individual operates are unvaried and
appropriate – which must mean critical – feedback is not given.
Debriefs
must highlight mistakes, errors of judgement and mistaken decisions,
and can usually only be worthwhile if coordinated by someone who
themselves has a high level of situational awareness. People just
don’t know what they don’t know. In this tragic incident, better
situational awareness might have given both the Team Leader (SS) and
the Site Manager the insight to realise that when the Cataraft was
anchored to the submerged vehicle, the dynamics of river hydraulics
were pretty much guaranteed to turn the Cataraft across the current
and result in rapid submersion. The team member holding onto the J
hook and chain attached to the vehicle would have had less than a
second to recognise their error and release the cable. Swiftwater is
unforgiving and its force operates faster than the human brain can
process.
So many errors of judgement, so many decisions adding up to a
calamity, but there is one thread that ties the entire episode
together and that is risk mitigation is very poorly understood. I’ve often heard people
say “I’ve done risk assessment.” In this exact incident, the
Site Leader believed he had done a risk assessment, but most times,
what people have actually done is develop a plan. Sometimes, more by happenstance than thought, the plan
introduces some elements that might mitigate the risk, but in the
overwhelming majority of cases, even among supposedly highly trained
individuals what people have is a plan. Risk assessments and the
corollary risk mitigation means I’ve looked at the situation and
the people and I’ve identified the most likely things to go wrong
and I have developed strategies to reduce or eliminate the
possibility of the most catastrophic events from occurring. Risk
assessment and mitigation is iterative, every new piece of
information must go into the model to refine the model. True risk
mitigation goes one step further and positions personnel and
resources in a position to effect a rescue when the unexpected and
unpredictable (most things aren’t truly unpredictable) happens.
Adventurers are drawn to dynamic environments. We love mountains
and glaciers where avalanches and rock fall and mountain weather
result in challenges, we love moving water whether on the ocean or on
a river, but the very dynamism that draws us in has the capacity to
overwhelm our ability to make reasonable decisions. We must learn to
think carefully indeed and realize that a plan is not a strategy to
reduce risk. Primarily, accidents such as this one are not the
result of the environment, or the people, or the weather, or the
topography, they are the result of decisions. Decisions which are
infrequently revisited or critiqued.
