Sharing hard-won lessons

“Of all the experts here today, I’m the one you’d least like to be,” the chief executive of Sir Edmund Hillary Outdoor Pursuits Centre told the EMA’s occupational health and safety Conference in Auckland last month.

“Seven people died while in our care and we want to ensure that nothing like that happens again – to ourselves or to others.” For this reason, Dr Grant Davidson said, it was important to share the lessons learned from the April 2008 tragedy, when members of a school party drowned while canyoning the Mangatepopo gorge under OPC supervision.

Among the lessons was the extreme difficulty of taking all practicable steps in an outdoor education setting, the need to protect and support staff during Department of Labour investigations, and the danger of “risk creep”, when risky activities are assumed to be safe because there have been no previous incidents.

Before the fatalities the centre prided itself on its approach to safety, Davidson said.“We thought we had the best processes possible, although you may not have got that impression from the media coverage.”

Within hours of the incident the OPC was at centre of four separate investigations – from the police, the Department of Labour, the media, and an independent industry team. “We determined to cooperate fully, put ourselves in front of the media, and try to live by the centre’s values.”

The ideal wasn’t always easy to live up to, however. “The police said they’d give us breathing space, but the DoL was around at 10am the next day,” Davidson said. “We’d been up all night dealing with horrendous things – carrying bodies out, dealing with the families, and so on – yet without asking me the department immediately began interviewing key people.”

It took Davidson’s intervention, telling the inspector that his team was in no fit state, for the process to be postponed. Over subsequent weeks, however, 30 of the centre’s 45 staff were interviewed – often by both the police and the DoL, despite OPC attempts to arrange joint interviews.

Reams of paperwork were also reviewed, with the police requesting – and receiving – records of every incident at the centre since 1976. “For eight months my life’s work was to answer questions.”

Dealing with the media was the most difficult part, however. “In the early days I was doing [media] interviews from seven in the morning until eight at night, and the parents [of the victims] were scrutinizing every word.”

In the face of sometimes-damning news reports, Davidson steeled himself to deal directly with the families. “It’s very hard, but it’s vital to do this as soon as possible. In the end we built a good relationship with them.”

When, several months later, HSE Act charges were laid, the centre’s lawyers advised a guilty plea. “It took a long time to get my head round that, but when you look at the standard for conviction we really had no choice. “We rely on the experts we employ to make decisions in a changing environment and if, in retrospect, it can be seen that those decisions were not the best ones, then we’re guilty.”

Davidson warned other employers to beware of risk creep. “You can start accepting a high level of risk because nothing has happened. Our policies said don’t go into the gorge when there’s a significant chance of the river rising, but we had been in before after rain without incident so we started to think it was okay.”

This story appeared in Safeguard Update newsletter of 10 August.

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