Anatomy of a Disaster
The multiplier effect on complacency
The following article examines the factors and events preceding the death of 15 year old Laura McDairmant during a Gorge Jumping activity on 15th July 2006. The article is based on the Determination by Johanna Johnston QC, presented on 24th June 2010. This article has surmised and paraphrased the original report but attempts to accurately reflect the findings. The original report can be found here:
Whilst this case is about a specific incident, following a specific activity at a specific location, the outcomes of the review clearly demonstrate issues which can be identified in any industrial or remote activity.
What this case demonstrates very clearly is that the death of Laura McDairmont was not due to one single failing but the accumulation of several failings – some serious and some seemingly trivial – which combined to form a critically unsafe activity, practiced in an unsafe manner at both the operational and organisational level.
Background
On the 25th July 2006 Laura was one of a group of young people participating in activities at an Outdoor Activity Centre. In the afternoon the group went with instructors to the Grey Mare's Tail Burn, Galloway Forest Park, to participate in an activity referred to as Gorge Jumping. This activity formed part of the programme offered at the Centre and consisted of jumping from height into a pool of water.
The Centre made use of two pools of water on the Grey Mare's Tail Burn for gorge jumping:
The first pool has over hanging sides and is in the form of a large pothole. There are two sites at different heights from which participants can jump. There are no obstacles to entry of the water from either of these points. The highest jumping off point is approximately 20 feet (6m) above the surface of the water. Laura had participated in gorge jumping at the first pool at a summer camp in 2005.
The second pool has formed at the base of the Grey Mare's Tail waterfall. At the edge of the pool there are ledges of rock, which protrude from the water level of the pool. There was one jumping point available for participants on a small clearing amongst vegetation. It is directly above a section of the protruding ledge of rock. This jumping point is 9.5 metres above the water level of the pool. The clearing there can only accommodate two people.
After lunchtime, the group arrived at the first pool for the start of the gorge jumping session. They were given instruction on how to make jumps into water. An instructor demonstrated a jump.
The instructors told the group that the jumps would be assessed by them to see whether or not a participant qualified to jump at the second pool. The instructors were looking for an ability to follow instructions, confidence and good body control in the air and on entry to the water. Laura made a number of satisfactory jumps and was assessed as having qualified to jump at the second pool.
An instructor repeated the instructions about how to make a jump. The group were told that they would have to jump off to the right from the jumping point in the direction that would be pointed out to them by the instructor. The instructor told them that if they did not step out far enough he would give them a push.
Laura said to a friend that she would go to the top and see if she still wanted to make the jump. She appeared to be a little less confident than she had been at the first pool.
The group climbed up to an assembly area above the jumping point. The instructor demonstrated a jump. He went to the jumping point. He took a large step out heading to the right from the clearing and in the direction of the centre of the pool. This took him away from the ledge of rocks and into the clear water.
The instructor then called on the participants to come forward one by one to make the jump. At the jumping point he asked if the person was still happy to do the jump. He then showed them where to place their feet and the direction in which to jump. He pointed out the position of the protruding rocks.
The instructor asked Laura if she was happy to jump and she stated that she was. He had no concerns about her confidence at that time. He pointed out the direction she should take when jumping. He then told her that she could make the jump when she was happy to do so.
Laura moved forward to the jumping point. She stepped back on one foot and then stepped forward over the edge of the rock face. She went to the right in the direction pointed out to her by the instructor. She had committed to the jump and she was out over the edge. She then turned her body to the left and twisted, possibly in an attempt to bring herself back on to the clearing. The momentum of her forward movement prevented her from regaining the clearing. She fell to the left in the direction of the rocks below.
The instructor reached out for her and tried to grab hold of her buoyancy aid. He did not get a hold of her. He was unable to assist her. Laura twisted further as she fell and the right side of her body was facing downwards.
Laura landed at the bottom of the rock face on the protruding ledge of rocks. She landed on her side with her face downwards. Her lower jaw and throat took the main force of the impact.
Conclusions
The following points have been extracted from the original report and categorised into relevant groups. What can be seen is:
The tragedy was not caused by any one particular catastrophic error but by the accumulation of many, lesser, errors.
Whilst adventurous activities have an inherent element of risk, the dangers which have materialised lay with the organisation's procedures and delivery of the activity.
Site
Because of the obscured rocks, which the participant needed to clear but could not see, the second pool was not a safe location.
The risk of a participant landing on the rocks could not be managed or reduced.
Once the participant had committed to the jump they could not be controlled to prevent an accident.
The Activity
Gorge Jumping is not a regulated activity as some other outdoor activities are.
There is no qualification for instructing or leading the activity however guidance from the Health & Safety Executive recommend both experience and at least a qualification at Mountaineering Instructor Award, Mountaineering Instructor Certificate or Mountain Guide (related skills).
Neither the Chief Instructor who originally introduced the activity, the Chief Instructor in post at the time of the incident or the activity staff delivering the activity, held these appropriate qualifications.
Internal Protocols
The Organisation did not require approval by board members for the chief Instructor to introduce new activities or site locations.
The Operations Director, at the time, was not aware of the activity being introduced.
The Operations Director – whilst having managerial experience – did not have experience or understating of wider adventurous activity and the activity industry.
There was no written evidence of the activity being approved by the organisations Technical Expert, nor had he provided any technical advice on the activity or location.
It was found that the Chief Instructor at the time of the incident did not hold the appropriate qualifications, nor have enough experience to fulfil that position.
There was no protocol for recording safety concerns.
There was no system for reporting concerns to the Operations Director.
Risk Assessment
There was no site-specific Risk Assessment for the activity, in accordance with the organisations policy, when the activity was introduced.
A written site-specific Risk Assessment was produced but did not include:
the name of the author.
the date it was written.
the identification of two locations for jumping.
details of the site.
the risks posed by the obscured rocks at the base of the second pool.
the risks were not categories as low, medium or high.
The Risk Assessment was not reviewed.
The Chief Instructor at the time of the incident was not aware that the activity was being conducted at the centre or that the location was being used by the centre for any activity
The Chief Instructor had not participated in the activity nor had he visited the site.
Missed Opportunities
In 2005 an instructor raised concerns about the safety of the second pool to the Chief Instructor. She did not raise the issue with anyone else at the centre.
Later in 2005 a second instructor raised concerns with the same Chief Instructor who appeared to take it seriously.
The issues was raised at a staff meeting, attended by the instructor who raise the concern, the Chief Instructor and the instructor who was leading the session at the time of the incident. At the meeting the Chief Instructor and the other instructor disagreed with the concerns. It was agreed that the Instructor with the concerns would not be asked to deliver the activity at the location.
The brother-in-law of the Chief Instructor narrowly missed injury whilst jumping into the second pool with friends in 2004. He told the Chief Instructor about the near miss.
Regulations
Whilst Gorge Jumping is not a Licensable activity under the AALA scheme, the centre had a responsibility under the Health & Safety at Work Act (1974) and was subject to the 1974 Act inspection scheme. The Inspection would be carried out by the Environmental Health Services of the Local Authority.
The Environmental Health Services Officers were not aware of the activities being delivered at the centre, nor had they visited the sites any of the activities.
The Environmental Health Service Officers had erroneously assumed that the Inspection by AALA would cover all activities ant that they did not have jurisdiction over the activities or locations being used.
AALA liaised with the Environmental Health Service insofar as providing them with a copy of the License issues to the centre but did not detail which activities they had inspected.