Mangatepopo Stream Tragedy - Case Study Example

Mangatepopo stream tragedy Mangatepopo Elim School stream tragedy (2008) What happened? On Friday, the 15th of April 2008, a 40 strong party from the Elim Christian College in Auckland embarked on a course for outdoor adventure offered by the Sir Edmund Hillary Outdoor pursuit Centre at the Mangatepopo stream in Tongariro National Park (Hersey, 2009). The party’s expectations were that they would have a fun afternoon involving a little bit of learning about the outdoors and plenty of adventure and exploring. However, the day took a tragic turn when Jodie Sullivan, the OPC instructor accompanying the party made the decision to that saw the group enter the Mangatepopo gorge and leave the rock ledge above the stream resulting in what came to be known as the Mangatepopo Stream / Elim School Tragedy of 2008. The decision was influenced by the fact that she did not receive an updated weather report, which could have influenced her to make a different choice. With some members of the group roped in pairs, she instructed them to enter the gorge at intervals of five minutes (Hersey, 2009). This was a controversial decision from a qualified outdoor instructor as the volume of water in the stream at the time can only be described as a maelstrom of water. Flash floods in the park had resulted in the stream’s volume increasing rapidly. Inside the gorge, they were sitting ducks to the flash floods. The floods claimed the lives 12 of six-year students and a teacher. The instructor and three other students were the only members of the party to enter the gorge and survive the floods. Two of the victims were about to celebrate their seventeenth birthday before the tragic event cut their lives short (More, 2006). The fact that there was a multiple loss of lives of young people with great potential in a scenario that could have been avoided, makes that event a great disaster. Why it happened? An independent review of the disaster revealed that it was not a first in the same area. The gorge had a history of near death encounters as well as several incidents of accidental deaths (Stuff, 2014). With such a record, one should expect that the OPC staff would always be prepared for the worst, which was not the case. A report by Grant Davidson, the organization’s CEO at the time faulted the staff for inadequately analyzing hazards and for not having up to date weather reports. The fact that the firm did not adopt his own safety recommendations during Davidson’s tenure casts doubts on his own ability to ensure the safety of clients. The fact that Sullivan was a senior employee after only 12 weeks of training and two months in the sector raises questions on the qualifications of employees in the sector (Hollingsworth, 2014). The instructor, student ratio acceptable in the adventure tourism industry also came to view as a result of the incident. All of these show that OPC was a time bomb waiting to explode and makes you wonder if the same can be said for other players in the sector at the time. The event highlighted the poor safety regulation systems and standards of risk management associated with outdoor activities at OPC. This made it a significant part of the New Zealand history because it resulted in the authorities making reforms to the legislation pertaining to the sector (Davidson, 2014). Latent failures Although errors in decision-making were the main cause of the Mangatepopo tragedy, the labor legislation at the time also bears part of the blame for the incident (Hollingsworth, 2014). In 2008, New Zealand’s adventure tourism sector lacked a definitive legislation specifically drafted to cover incidences concerning the health and safety of the would-be participants on the field. Instead, the Health and Safety in Employment Act served as the law meant to determine the direction of the sector (Health and Safety in Employment Act 1992, 2008). The act charges employers with the duty of protecting his or her employees and customers. The act stated that an employee was eligible for compensation if the employer knowingly puts him or her in a line of work that ends up endangering the health of the employee. The same also goes for the customers. Case in point is the scenario created by OPC management by trusting Sullivan, an inexperienced and therefore unqualified employee, with the responsibility of manning a group of forty in a hazardous area. As a result, the OPC administration is indirectly responsible for the tragedy. The fact that Sullivan had only gone to the gorge five times prior to the accident and could not therefore guarantee the safety of others strengthens this argument. It is for this reason that the Department of Labor handed OPC a $40000 fine and ordered the organization to pay $440,000 as compensation (Binning et al., 2014). The absence of this section of the Act would mean that there was no case against OPC. However, the general nature of the Act also meant that there was no clear guideline on the qualifications required for one to work in the adventure tourism sector, specifically Canyoning. A qualified instructor during a field excursion in a gorge or a canyon needs to possess a certain set of skills that will help in resolving of situation that may arise (Opc.org.nz, 2014). These include abseiling, rock climbing, river rescue, first aid, risk analysis as well as weather interpretation. Active failures An analysis of the incident shows that Sullivan may not have had the proper set of skill that would have helped the students to abscond the danger successfully. However, if the legislation at the time had properly defined the qualifications and skills that one needed in order to be an instructor in the sector, a professional who would have mitigated the situation by properly analyzing the situation and making better decisions would have guided the group. Outcomes Finally, the sector’s regulating act during the period of the tragedy did not set licensing parameters. According to Davidson, OPC had set a clear system that was designed to avoid such situations and possibly reduce their magnitude when they do happen (Opc.org.nz, 2014). However, on the day of the disaster, the employees failed to implement the system, which resulted in the loss of lives. In other professional fields like law, medicine and teaching, one is required by law to have a practicing license that needed renewing. If one were involved in an incident serious enough to deserve punishment, he or she would have his license revoked or cancelled. This promotes accountability among individuals. In this case, the employees of OPC failed to implement key parts of the process that leads up to a field excursion as well as during the exercise. A license regulating regulation would have prevented such acts as the unavailable up to date weather report and the absence of the manager who would have prevented the inexperienced instructor from going into the gorge (Binning et al., 2014). In this case, there would not be an accident in the first place, let alone a tragedy. Ericson (2007) defines risk management as a wholesome process that entails identifying possible hazards and their causes, determining the effects of the consequences, working out the probability of them occurring before using all this information in deciding whether the risk can be accepted or if there are correctional measures that one needs to take to make them acceptable. The ISO 31000 is a document that established a standard in the field. It explains that risks should be managed using the following step (Zink and Lieberman, 2003): Risk assessment- risk identification; the source, frequency of occurrence and the effect, risk analysis and risk evaluation Risk treatment Risk control If these steps are followed, the risk becomes acceptable (Iso.org, 2014). In the case of the Mangatepopo gorge tragedy, if the OPC had utilized these standards in the management of the risks associated with walks in the gorge, the outcome would have probably been different. Starting with identifying the risks, a survey of the gorge to get the clear picture of the characteristics would be first. This would be accompanied by the Coroner’s report on the accidents that have occurred in the past. The result would be that feeling was the most frequent risk with flash flooding occurring twice a year. However, since the effects of flooding outweigh those of people falling into the gorge, the analysis would show that the former needs prioritizing. An evaluation of the risk’s frequency and effect would show that although the occurrence is rare, ignoring the risk is not possible as it is not acceptable in the running of the organization. This would mean that OPC need to put stringent measures in place to mitigate the effect of the risk that is flooding, should it occur (Hopkin, 2012). This is the treatment step. Here experts would have to be consulted. This will see the coming to light of such ideas as the development of escape routes, laying of cords for holding onto, establishment of proper communication channels to aide in warning and equipping customers with suitable pieces of clothing. Treatment would also involve employing adequate instructors with adequate training that would be useful in the situation. The company would have also revised its policies to ensure that field managers with an up to date weather report were present during the excursions to give the instructors advice on what to do. The implementation of these and other possible safety measures would have resulted in the victims of the incident as well as the OPC fraternity being ready for the increase in stream flow (Dickson & Gray, 2012). Therefore, everyone would have been out of the water safely before the rapidly flowing water was upon them, which would have surely averted the disaster. Better yet, the party would not have gotten into the water. The Mangatepopo stream/ Elim school tragedy is one of the significant disasters in New Zealand history as the disaster resulted in the loss of seven lives through a chain of events that was avoidable. It revealed the level of incompetency associated with the adventure tourism sector at the time. It also showed the country had poor safety regulations that the legislation offered. However, there is also a positive side to the story as the incident resulted in the review of safety laws and standards that has resulted in the saving of lives many folds of those lost in that tragic event (Risksociety.org.nz, 2014). . References Binning, E., Eriksen, A., Gay, E., Ihaka, J., Donovan, B., & Eriksen, A. (2014). OPC missed warnings which could have prevented tragedy (+photos) - National - NZ Herald News. The New Zealand Herald. Retrieved 26 September 2014, from http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10504366 Davidson, G. (2014). The FLASH Rating (1st ed.). Auckland. Retrieved from http://www.supportadventure.co.nz/system/files/FLASH%20-%20Risk%20Comms%20V7.pdf Dickson, T. J., & Gray, T. (2012). Risk management in the outdoors: A whole of organisation approach for education, sport and recreation. Cambridge: Cambridge University Press. Ericson, C. A., & Wiley InterScience (Online service). (2011). Concise encyclopedia of system safety: Definition of terms and concepts. Hoboken, NJ: Wiley. Health and Safety in Employment Act 1992. (2008) (1st ed.). Retrieved from http://www.legislation.govt.nz/act/public/1992/0096/latest/versions.aspx?av=True Hersey, P. (2009). High misadventure: New Zealand mountaineering tragedies and survival stories Auckland, NewZealand: New Holland. Hollingsworth, R. (2014). A Discourse Analysis of Post - World War Two Outdoor Education Practice in New Zealand. (1st ed.). Auckland: Auckland University of Technology. Retrieved from https://aut.researchgateway.ac.nz/bitstream/handle/10292/2574/HollingsworthR.pdf?sequence=3&isAllowed=y Hopkin, P. (2012). Fundamentals of risk management: Understanding evaluating and implementing effective risk management. London: Kogan Page. Iso.org,. (2014). Online Browsing Platform (OBP). Retrieved 26 September 2014, from https://www.iso.org/obp/ui/#iso:std:iso:31000:ed-1:v1:en Moore, C. (2006). Take a kid outdoors. Auckland NZ: New Holland. Opc.org.nz,. (2014). One place left on Risk Management Training Course! | Sir Edmund Hillary Outdoor Pursuits Centre of New Zealand. Retrieved 26 September 2014, from http://www.opc.org.nz/2014/01/one-place-left-on-risk-management-training-course/ Opc.org.nz. (2014). OPC Safety | Sir Edmund Hillary Outdoor Pursuits Centre of New Zealand. Retrieved 26 September 2014, from http://www.opc.org.nz/safety/ Risksociety.org.nz,. (2014). Standards and handbooks | Risk Society. Retrieved 26 September 2014, from http://www.risksociety.org.nz/Standards_and_handbooks Stuff. (2014). A tragedy that could have been avoided. Retrieved 26 September 2014, from http://www.stuff.co.nz/sunday-star-times/features/3542548/A-tragedy-that-could-have-been-avoided Zink, R. , and Lieberman, S. (2003). Risking a debate – refining risk and risk management: a New Zealand case study. New Zealand Journal of Outdoor Education ; 1(2), 63 – 76 Read More