This is probably one of the single most unpleasant things to read as an outdoor education and risk management professional, but it’s vitally important that any teacher taking a group of students anywhere reads and learns from the extremely tragic experiences that are outlined in any coronial inquest. The lessons learnt from these, must inform our approach to risk management and safety for every program we run.
There are often two dramatically different types of coronial reports. Firstly, the tragic accident, which could not be reasonably foreseen, and despite all efforts to respond, a life is lost. However, more often than not, it’s the second type of report and coronial finding that clearly demonstrates systemic failure and usually a series of events which with each step/poor decision/delay, leads to a fatality.
Whilst both are undeniably tragic, the second leaves families, schools and all those involved destroyed for life. As you read through one of these, the warning signs, deterioration of conditions and clear evidence that there’s a problem is usually abundantly clear. Whilst many would say it’s easy to see that in the rear-view mirror, which I agree is entirely true, as hindsight is very powerful, but often the obvious warning signs are there. Thus, understanding your environment, your group and the risks involved in what you’re doing, should have already provided you with enough insight to take the action needed to prevent a situation deteriorating into a critical or fatal situation.
What’s vitally important from this is the need for situational awareness. Instructors and teachers need to be aware of a range of factors (which are usually outlined in a risk assessment) and ensure they’re proactively considered and managed. Reading coronial reports is a horrible, but important part of that skills development for being aware of conditions and situations which have led to irreversible and tragic consequences.
I found myself in one such situation a number of years ago. We were out hiking west of Nowra and heading in towards Kangaroo Valley. It was a bright sunny and hot afternoon in February and a massive, angry storm rolled in faster than crazed shoe shoppers on Boxing Day. We were suddenly trapped on a ridge with pelting rain, lightning striking all around us and drilling the ground with no pause between the lightning and the deafening concussion of the thunder. Strike after strike after strike, it pinned us down. Perched on our packs in the ‘lightning position’ we could do nothing else other than stay clear of trees and wait out the storm. However, the storm persisted and hour after hour we had no option but to stay put.
Suddenly there was a break in the storm and the other group leader had the idea that we should keep going despite the conditions around us. We were heading towards a river which needed to be crossed to get to the camp site. We had saturated gortexes and some students were showing early signs of hyperthermia. It was not a good idea to press on, but full of bravado and telling the group that if we didn’t, the other group would think we were weak, a nauseating feeling hit me. This didn’t feel right. We had too many factors at play. The extreme weather, the equipment failure and the condition of the students. When something feels wrong, then you must act immediately. It’s not a matter of waiting to see what happens. Stop, regroup, bring in other resources and respond before things spiral out of control.
This is the critical tipping point of any coronial inquest. You can often determine the point of no return where the decision to continue inevitably led to the fatality and often it’s based upon poor thoughtless decision making, where there is plenty of evidence that it’s time to stop, regroup and rethink everything. Thankfully, the nauseating feeling on the mentioned trip, was telling me things are deteriorating and we need to change tactics. We waited until the main storm passed, went and grabbed the 4WD and then moved the group to an alternate campsite. Soon after setting up we had a fire going and everyone had something warm to drink.
Whilst it’s painful and distressing to read coronial inquests, it’s vitally important that you do as part of your ongoing risk management training and professional development. Understanding the experiences of others and the tragedies of the past can help us to make better decisions and ensure the safety of our groups into the future. It’s those lessons learned, that are powerful and stark reminders that risk management must be a living, breathing approach to running any program and not just a document which is dusted off when it’s subpoenaed by the coroner.
As part of your on going risk management, it’s well worth regularly reviewing and workshopping coronial reports with your team to ensure the situational awareness and those tipping points are at the forefront of everyone’s minds every time they’re out with a group to ensure everyone has a safe, challenging and enjoyable experience.