Years ago, two of my instructors had a near-miss with a group on a rising river. As the program director at the time, my initial reaction was anger. I was pissed at them.
Nobody got hurt, at least not physically. I told the full story in Two Good Instructors, One Bad Decision.
In my office afterward, I asked the instructors to walk me through their day, one decision at a time. Everything they said seemed like a reasonable, rational decision. When I dug deeper, I began to see that every detail pointed at something we decided months, sometimes even years, earlier. By the time they left my office, I wasn’t frustrated anymore. I was embarrassed.
We gave them their itinerary of where to camp each night.
Sure, they could choose a different site, but they had to make it to the takeout we’d pre-selected by Friday. They had to make it there because it’s the information we gave the bus drivers and truck drivers. Changing their pickup location and time was not only a pain (they always threw a fit, even if the location changed by just a couple of miles), it also cost us in penalty fees. And, after all, the kids should be getting a similar river course as the other student groups from the school, right? We had a written policy that everyone would do a water comfort assessment (swim assessment) before paddling downstream. Realistically, that means on day 1 or first thing in the morning on day 2, after an already long day of travel and setting up camp.
I went into the debrief expecting a conversation about instructor judgment. I came out with a deeper understanding of social and cultural norms, and competing priorities and trade-offs. We didn’t have adequate controls for those. We didn’t have an essential safety policy that said no one can enter the river at a certain CFS or in a rising river. It’s no wonder the instructors prioritized the learning goals and itinerary over physical safety. That was on me, the program director. Not them.
In grad school, I thought about this incident a lot.
My research mentor and now friend and collaborator, Dr. Clare Dallat, had just finished her PhD showing that roughly 80% of risks are introduced into the program’s systems upstream, before anyone sets foot in the field (Dallat et al., 2017).
More than just an interesting bit of risk management trivia, this statistic is actually quite instructive. It tells us where to go to learn more, and, as program administrators, where to place our efforts.
Let the instructors use the good judgment you hired them for. But make it easy on them. Give them the right-sized ‘container’, fit to the goals and purpose and tolerance of your program to practice their judgment within. The ‘container’ is built in the design and planning stages, in the off-season, pre-season, and during program preparations, and after the program in the review and reconciliation stages.
The ‘container’ was built by trade-offs. I traded flexibility on the river for lower transportation costs, fewer arguments with drivers, and a course itinerary that looked the same for every group. They seemed like reasonable trades at the time I made them, years before this incident occurred. At some point along the way, each of those decisions just became “the way we do things here.” The instructors inherited them as established rules and boundaries. As a result, they had to work out their own trade-offs standing next to a rising river.
Look around this week.
What trade-offs might you be subconsciously making? Where, among those decisions, is the burden of safety displaced to the frontline, field staff?
Is it still a good trade?
P.S. I wrote a two-part introduction to systems thinking on the blog, Part I and Part II. A program risk review asks the same upstream question across every planning area, instead of one problem at a time. I do those reviews for schools and outdoor programs, and I coach the program directors and risk managers who lead the changes afterward. Reply if you want to talk it through.
Stu: glad to see Clare acknowledged for the cutting-edge work she has done.