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On the 18th August 2016, Victorian Coroner Audrey Jamieson released her finding into the fatal drowning of Paul Rayudu at the WaterMarc facility in Melbourne, Australia.

Recommendations aside, the Coroner’s final words on the matter were “No one should drown at a public pool”, and this one sentence has me feeling uneasy. I don’t know of a lifeguard, centre manager or organisation that doesn’t go to work every day with this exact aim in mind.

When managing any risk, there is an agreed hierarchy that outlines which controls are the most effective and hence should be implemented first;

  1. Elimination
  2. Substitution
  3. Engineering
  4. Administration
  5. Personal Protective Equipment (PPE)

When you list the controls used for managing the risk of drowning, most of them are administrative. So far, in Australia, we don’t have a measure that doesn’t rely either completely or partially on administrative controls. Even Poseidon relies on the skill of lifeguards to get to, retrieve and perform CPR on the casualty.

Administrative layers of protection are fragile and yet, according to fatal drowning data from the Royal Life Saving Society of Australia, and annual attendance estimates from University of South Australia, public swimming facilities have been the safest place to swim in Australia, for some time (15-year average of 1 fatality every 37 million visitations).

Fatal drownings at public facilities now come before the courts so rarely that maybe Coroners and Counsel have difficulty understanding how they could possibly occur. Certainly we’ve not had a Coroner come out and say that no one should drown within the flags on a beach… and yet people do. No other sector is held more accountable.

The other thing that adds fragility is that lifeguards and duty managers are human, and humans make errors. There are many studies into human reliability rates, probably the most notable the US Nuclear Reactor Safety Study of 1975. The study states that for a critical routine task, a trained human will make an error once in every thousand times. While the number is low, it doesn’t really matter. The fact remains; humans make errors.

Not only do humans make errors but things happen. Decisions are made and while they may not produce an error they do produce an outcome.  This outcome may intersect with another outcome, perhaps a decision made by another person, which combined can have fatal consequences.

At public swimming facilities right across Australia, errors occur and things happen every shift. Errors and things, that in isolation mean nothing and have no consequence. Sometimes two errors might occur and one thing might happen at the same time, and still no consequence. We might not recognise it but essentially these are near misses, or near hits as I prefer to call them.

In reading the WaterMarc report I can break it down into 10 errors and things that had to happen, in sequence, for the drowning to occur. Some errors and things where completely unrelated. Others had probably happened before with no consequence. Some errors and things were outside of the control of the other party. Finally, it ends with two non-swimmers in deep water, no lifeguard watching the pool and 70 other patrons who, either don’t see the drowning or don’t recognise the it. It’s an incredibly complex web of events.

In terms of searching, looking for drowning amongst a group of people all doing things that look like drowning, it is difficult.  No one should be surprised that a lifeguard can miss the real deal when faced with 37 million false positives annually.

With the benefit of hindsight and from the comfort of our own armchairs, it would be easy to read the report and be critical of how the centre was run that day. It should be remembered that the report is an abridged version. The Coroner states;

In writing this report, I do not purport to summarise all of the evidence, but refer to only in such detail as warranted by its forensic significance and the interests of narrative clarity.

As a person who attended the inquest I can tell you it is harder to be critical when you’ve experienced the personal side of this story; the anguish & sadness of Paul Rayudu’s fiancé, the lifeguards and duty manager, all of whom are no doubt dealing with their own personal responses to this event. The uncertainty and sadness felt by the centre manager and those higher in the organisation. All of these people will be going through the various stages of grief. The support I saw the organisation offer their staff during the hearings was impressive.

We now have another organisation and more lifeguards who have gained experience that is difficult to gain in a training room. Belgravia Leisure have shared these lessons at various industry events and this is a big change to the way any organisation has dealt with these events in the past, especially a leisure management company. I think it’s great what they have done and hope the lifeguards involved remain with the industry. Their learning and attitude toward safety will feed directly back into our drowning prevention strategies.

From a risk management point of view the other aspect that should be looked at is why this wasn’t a double fatal drowning. While some things went wrong on the day, some things went right too and it is equally important for us to understand those. Whenever we don’t lose someone we should be asking “Why not… what went right today?”

It is important that we continue to do everything so far as is reasonably practicable to prevent these events. It is also essential we get better at articulating how these events might occur to the courts. Due diligence is important to what happens in both instances.

I’m going to steal a few thoughts here from a Melbourne mentor of mine, Richard Robinson of r2a Due Diligence Engineers. We need to figure out how to align the laws of man with the laws of nature. Currently, the laws of man seem to be saying that no one should drown at a public pool. The laws of nature suggest otherwise. We are all human, both lifeguards and swimmers. We make errors and we can’t breathe water.

No one should drown at a public pool and yet, despite best efforts, they do, albeit rarely. We all wish it were otherwise.