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Wednesday, December 16, 2015

Post incident debrief

In the outdoor recreation and education industry, accidents - or incidents if you prefer - are inevitable. It is a standard practice to debrief an incident to see what in your risk management program is effective, or where there are holes in safety creating areas of potential risk, and most importantly what can we learn from the incident to prevent similar incidents in the future.

You can never remove all risk. These are inherently risky games we play, but we can work hard to mitigate the risk.

This morning I read Rick Ridgeways account of the Doug Tompkins fatal incident, and my brain immediately slipped into debrief mode. When assessing a situation like this - and you should always assess a situation like this, there is always something to learn - here are some of the questions I start to ask myself. I need to stress, I am not questioning Mr. Ridgeways or Mr Tompkins actions. Merely trying learn from a tragic accident.

What was the cause? I want to know about the gear involved and the gear worn. Weather. Experience. Hydration and Nutrition. Other risk factors. Think about those while you read Mr. Ridgeways account:

The trip started as a four-day paddle along a remote section of Lago General Carrerra, in Patagonian Chile. There were six of us on the trip in two single and two double kayaks. Between us we had well over a hundred years of combined experience. But Doug and I also had a double kayak with a finicky rudder. On the third day of paddling a growing crosswind created challenging conditions, and with our faulty rudder Doug and I were unable to avoid a broaching wave that capsized us.
We knew immediately we were in a grave situation. As the wind and current pushed us toward the center of the lake, we had no way of knowing whether our companions in the other boats—who were ahead of us and out of sight around a point we had been working to round—knew of our predicament. We realized we had about 30 more minutes to survive; the water temperature was perhaps 38 or 40 degrees Fahrenheit. We tried and failed four times to right the boat and paddle it, but the wind and waves were too strong for us to maintain balance and the boat was too flooded. Eventually, we had to decide whether to attempt to swim or to stay with the capsized boat. The boat, pushed by a perpendicular current, was drifting towards the center of the lake. Staying with it was putting us in an even more difficult if not impossible position.
We decided to abandon the boat and began to swim toward the point. It was tough and I realized, against the current, it was likely impossible to reach the point. Time was also against us. I was slowing and even with a life jacket I was pushed under by the larger waves. I could see Doug and assumed he was in the same situation. I was hypothermic and I was starting to drown. For a few minutes I gave in—just let it go—but then snapped back. Then I saw our companions paddling towards us against the wind—now at about 40 knots with gusts much stronger to 50 knots and more (later confirmed from weather measurements for the lake that day).
Two of our companions, Jib Ellison and Lorenzo Alvarez, reached me in a double kayak. I hung onto the stern loop, still in the water, while they paddled into the wind to reach an eddy behind the point. Between the waves and the wind, there was no point for me to try to get onto the boat. I had to dig deep—I think as deep as I’ve gone. It seemed to take forever. I remained focused on my hands and holding on to the loop until I realized I was on a rock. Then I lost consciousness and my next memory was of lying in front of a fire.
Doug was not so lucky. Our other companion, Weston Boyles (who had been paddling with Yvon Chouinard but left him in order to attempt Doug’s rescue), gave a supreme effort—attempting to paddle Doug to safety but unable to overcome the power of the wind and current. Doug held on for another half-hour, kicking as much as he could, but lost consciousness. Weston risked his own life to keep Doug’s head above water as he fought to reach shore. By the time they landed, Doug was too hypothermic to survive.
Okay, in the first paragraph we learn that they are in a remote location, as a group they have a lot of experience. Rick and Doug have a double also called a tandem kayak with a finicky rudder. Because of the rudder the kayak turns sideways to the waves and rolls. Here are the follow up questions I would ask if I had access:
When did you know the rudder was finicky, before the trip? before that day? When you discovered the rudder was finicky, could you have found another beach to land on, short of your destination to fix the rudder or wait out the wind? Was the boat checked before the trip began? 
In paragraph two we learn that because of their finicky rudder they aren't able to keep up with the group who are now out of sight and around a point, this is a tremendous error in leadership and judgement among people who know better. Staying with the boat is generally a good idea, as it offers much better visibility, but if it is getting pulled away from a safe location it is a crap shoot. Here are my follow up questions. What exactly were you wearing (though even a drysuit in 40 degree water is cold) Did you have bilge pumps and paddle floats? (could the boat have been outriggered with a paddle float for stability and then bilge pumped empty?) Could you get on top of the boat to get your body out of the 40 degree water? With wind in 40 to 50 knot territory, did we hear a weather report before hitting the water? Did we have an opportunity for weather updates while paddling? 
Paragraph 3 The remainder of the group realize something is wrong and come back for them. The tandem rescues Rick - by the way, this is what the handles on the ends of your boat are for, I have written about this in the past! - but a single can't make headway with Doug against the wind. We know how this plays out. 
There were unfortunately a number of mistakes made that started with a finicky rudder. Then a failure to make a "no go" call when faced with high wind, or a bail out call when that wind was getting worse. Then the group getting separated. There are still a lot of questions to be answered and we probably won't get them (Clothing, weather reports, what was actually wrong with the rudder, bilge pumps)
I wasn't with them, but I suspect the biggest issue was that a in big group of highly skilled adventures, no one wanted to say "these conditions are too much, lets find a beach and call it a day". 
In fairness, and because I have a lot of respect for the people involved, my questions may all be unfounded. Maybe the rudder didn't act up until they were paddling that day? Maybe they were in drysuits with ample insulation. Maybe in bad conditions they told the group not to wait, so fewer people would be at risk. Maybe in the rough water they couldn't set up an outrigger, or pump out the kayak. Maybe they had weather information and it was wrong - though I know that is a stretch, the weatherman is NEVER wrong! Maybe earlier in the day they realized they needed to get off the water, and couldn't. 
The point of this exercise is to look at the incident, and see what could have prevented a fatal outcome. So we can learn, and next time prevent something like this from happening. Think about your own trips, and near misses. Have a solid plan for future trips, and think about the what if's. What if the weather goes bad while we are on an exposed coast? Have you ever practiced getting into a kayak in rough water? When you are cold? When you are tired? 

1 comment:

  1. I'm so glad you wrote this as I spent a while thinking about it when I first heard he had died. I kind of figured it was a complicated scenario and was hoping you'd write about it.

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