13 year old non swimmer drowns

[Captain Pegg]

In response to Jess-- and PaulG it is about differing risk profiles.

 

The risk at all locks - or narrows - is not the same. The canal factors and the nature of the danger may be the same or similar but the environmental factors are different and that is why a different approach is required.

 

In the case of the Rochdale Canal incident it is likely there was easy access to the canalside from adjacent housing and evidence of past misuse of the canal. There must be other locations on that same canal where there is no direct access to the canal side from adjacent land, there are no immediately adjacent houses and there is no evidence of misuse. The asset owner is required to manage the risk associated with the same event - drowning - but the mitigation measures would be focused on the former and may not be necessary at the latter even if they are deemed to be so at the former.

 

The Smethwick and Worcester Bar scenario is the same. Taking into acccount all the factors the risk would likely to be calculated as far greater at Worcester Bar than Smethwick. If the circumstances of Smethwick can be demonstrated to be an isolated incident of misuse at that location that just happened by chance to have been there and not somewhere else then it doesn't follow that measures are required at Smethwick. However the evidence is that people can drown while jumping locks so the logical conclusion is to provide mitigation at places where there is evidence that people misuse the canal in this way; of which Worcester Bar was likely top of the list.

 

Risk is about managing probability and consequence but that doesn't translate easily into actual events since those are binary - they either happen or they don't - and predicting where they will actually happen isn't possible at a site by site level. The degree of consequence also involves a hefty dose of luck and conspiracy of factors. Therefore it has to be approached on a system wide basis and with the realisation that nature will sometimes be a complete bitch but that is never an excuse for not doing something within your means.

 

JP

[mross]

In response to Jess-- and PaulG it is about differing risk profiles.

 

The risk at all locks - or narrows - is not the same. The canal factors and the nature of the danger may be the same or similar but the environmental factors are different and that is why a different approach is required.

 

In the case of the Rochdale Canal incident it is likely there was easy access to the canalside from adjacent housing and evidence of past misuse of the canal. There must be other locations on that same canal where there is no direct access to the canal side from adjacent land, there are no immediately adjacent houses and there is no evidence of misuse. The asset owner is required to manage the risk associated with the same event - drowning - but the mitigation measures would be focused on the former and may not be necessary at the latter even if they are deemed to be so at the former.

 

The Smethwick and Worcester Bar scenario is the same. Taking into acccount all the factors the risk would likely to be calculated as far greater at Worcester Bar than Smethwick. If the circumstances of Smethwick can be demonstrated to be an isolated incident of misuse at that location that just happened by chance to have been there and not somewhere else then it doesn't follow that measures are required at Smethwick. However the evidence is that people can drown while jumping locks so the logical conclusion is to provide mitigation at places where there is evidence that people misuse the canal in this way; of which Worcester Bar was likely top of the list.

 

Risk is about managing probability and consequence but that doesn't translate easily into actual events since those are binary - they either happen or they don't - and predicting where they will actually happen isn't possible at a site by site level. The degree of consequence also involves a hefty dose of luck and conspiracy of factors. Therefore it has to be approached on a system wide basis and with the realisation that nature will sometimes be a complete bitch but that is never an excuse for not doing something within your means.

 

JP

Cogently stated!

[PaulG]

In response to Jess-- and PaulG it is about differing risk profiles.

 

The risk at all locks - or narrows - is not the same. The canal factors and the nature of the danger may be the same or similar but the environmental factors are different and that is why a different approach is required.

 

In the case of the Rochdale Canal incident it is likely there was easy access to the canalside from adjacent housing and evidence of past misuse of the canal. There must be other locations on that same canal where there is no direct access to the canal side from adjacent land, there are no immediately adjacent houses and there is no evidence of misuse. The asset owner is required to manage the risk associated with the same event - drowning - but the mitigation measures would be focused on the former and may not be necessary at the latter even if they are deemed to be so at the former.

 

The Smethwick and Worcester Bar scenario is the same. Taking into acccount all the factors the risk would likely to be calculated as far greater at Worcester Bar than Smethwick. If the circumstances of Smethwick can be demonstrated to be an isolated incident of misuse at that location that just happened by chance to have been there and not somewhere else then it doesn't follow that measures are required at Smethwick. However the evidence is that people can drown while jumping locks so the logical conclusion is to provide mitigation at places where there is evidence that people misuse the canal in this way; of which Worcester Bar was likely top of the list.

 

Risk is about managing probability and consequence but that doesn't translate easily into actual events since those are binary - they either happen or they don't - and predicting where they will actually happen isn't possible at a site by site level. The degree of consequence also involves a hefty dose of luck and conspiracy of factors. Therefore it has to be approached on a system wide basis and with the realisation that nature will sometimes be a complete bitch but that is never an excuse for not doing something within your means.

 

JP

Of course it depends on individual assessment.

However, I find it hard to believe that the risk at Worcester Bar (where the lock is permanently full of water, in a busy area straight outside a cafe and in an area that is covered by CCTV and AFAIR no-one has drowned in living memory) is greater than Smethwick (where local yoof are known to gather and there have been two recent fatalities as a result of aforesaid yoof trying to jump an empty lock).

Edited November 25, 2016 by PaulG

[Mike Todd]

But if you look at a map you will find that Lock 62 (alleged culprit) is relatively away from housing and more rural.

 

Also, IIRC, the locks at the Leeds end of L&L that are supervised are also relatively rural.

 

The lock above Reading that attracts macho teenagers is also away from housing.

 

If you attend to my earlier point about think things through you might see that rural locks may be greater risk than urban ones just because there is less probability of someone being around to help. Also there may be greater difficulty in emergency services being able to get there.

 

The simple fact is that all locks have risks, as does every stretch of a canal. What is at issue is what is a reasonable or proportionate response to each risk. Few people think that erecting notices actually reduces risk in the sense of modifying behaviour. Sadly, all too often the reason notices are put up is so that post hoc the risk 'owner' can then say that they are not at fault and cannot be sued.

[Canal Cuttings]

As I touched on in an earlier post, exactly how dangerous is swimming in an full lock? (Genuine enquiry). If the kids are harried from pillar to post and not allowed to do anything involving exercise or fun, they will run out of things to do and places to go. Alternatives include staying at home and dying at an early age of obesity, and hanging around the town centre mixing with undesirables. I'd never consider swimming in a canal, and neither would my children, but that's not the lifestyle of these children. You could say they have applied their own crude risk assessment, as they have been swimming here regularly with no problems until a non-swimmer decided to jump in.

[PaulG]

As I touched on in an earlier post, exactly how dangerous is swimming in an full lock? (Genuine enquiry). If the kids are harried from pillar to post and not allowed to do anything involving exercise or fun, they will run out of things to do and places to go. Alternatives include staying at home and dying at an early age of obesity, and hanging around the town centre mixing with undesirables. I'd never consider swimming in a canal, and neither would my children, but that's not the lifestyle of these children. You could say they have applied their own crude risk assessment, as they have been swimming here regularly with no problems until a non-swimmer decided to jump in.

If you can swim, probably not very dangerous at all.

There's even a convenient ladder to help you to climb out.

 

When I was a kid we spent a lot of time swimming in the local river, regardless of parents telling us not to do it. Somehow we often "accidently" fell in, usually on hot days in the summer.

 

In Tewkesbury town, the local kids used to swim right in front of the sluice at Abbey Mill. It was locally known as the "32" AFAIR because the water was supposed to be 32 ft deep. Kids used to dive off the bridge and see how deep they could get. Assess the risk on that one!

[Dave_P]

Of course it depends on individual assessment.

However, I find it hard to believe that the risk at Worcester Bar (where the lock is permanently full of water, in a busy area straight outside a cafe and in an area that is covered by CCTV and AFAIR no-one has drowned in living memory) is greater than Smethwick (where local yoof are known to gather and there have been two recent fatalities as a result of aforesaid yoof trying to jump an empty lock).

The sign and railing at the Worcester Bar are there for safety reasons but also to protect the safety and security of moorers on the basin. The commercial boats were being robbed and vandalised on a very regular basis to the point where the operators were paying a security guard to patrol the basin every night. The basin is supposed to be locked up at night. There are now fewer bar jumpers. I do have issues with the way the railings were installed though.

 

When I moored at GSB, watching the jumpers was a popular spectator sport among moorers, a bit like watching gladiators in the roman circus. Many times the person failed to make the jump and ended up wet and cold. Sometimes they went in directly in front of an oncoming boat (it's more exciting to jump across in front of a boat), sometimes they half fell in and got bruised and scraped on the copings on the far bank. Sometimes they smashed hard against the opposite bank, breaking ankles, legs, ribs. Ambulances were called on a few occasions.

 

Nobody has drowned in recent times, but the amount of people jumping across had been increasing. Do we only take a reactive approach to H&S? Isn't prevention a good idea too?

[PaulG]

The sign and railing at the Worcester Bar are there for safety reasons but also to protect the safety and security of moorers on the basin. The commercial boats were being robbed and vandalised on a very regular basis to the point where the operators were paying a security guard to patrol the basin every night. The basin is supposed to be locked up at night. There are now fewer bar jumpers. I do have issues with the way the railings were installed though.

 

When I moored at GSB, watching the jumpers was a popular spectator sport among moorers, a bit like watching gladiators in the roman circus. Many times the person failed to make the jump and ended up wet and cold. Sometimes they went in directly in front of an oncoming boat (it's more exciting to jump across in front of a boat), sometimes they half fell in and got bruised and scraped on the copings on the far bank. Sometimes they smashed hard against the opposite bank, breaking ankles, legs, ribs. Ambulances were called on a few occasions.

 

Nobody has drowned in recent times, but the amount of people jumping across had been increasing. Do we only take a reactive approach to H&S? Isn't prevention a good idea too?

Thanks Dave - I hadn't considered the security aspect. And to answer your question, of course it should be both.

However, IMHO there is a big difference between a perceived risk and one that has been proven to exist.

 

I still think that the two examples show an inconsistent approach.

 

At one site, many people are known to have jumped the lock. No serious injuries resulted.

At the other site, the number of "jumpers" is unknown, but two people have lost their lives.

 

One site gets a sign, the other one doesn't.

Whether signage actually does anything to improve H&S, of course, is another issue..

[Captain Pegg]

Of course it depends on individual assessment.

However, I find it hard to believe that the risk at Worcester Bar (where the lock is permanently full of water, in a busy area straight outside a cafe and in an area that is covered by CCTV and AFAIR no-one has drowned in living memory) is greater than Smethwick (where local yoof are known to gather and there have been two recent fatalities as a result of aforesaid yoof trying to jump an empty lock).

I wasn't trying to compare the risk in the direct sense merely demonstrate the logic as to why a mitigation may be applied to a place that has no history of a particular outcome but not to one that has. For an organisation like CRT reputational risk will weigh heavily into the calculation of risk profile. That's another factor that may have influenced Worcester Bar. Without knowing the logic or even if has been applied equally to both locations I couldn't comment on whether CRT have got it right so I am not disagreeing with you.

 

The argument that 'it hasn't happened before' isn't a good one in making risk decisions. Past evidence certainly features in the calculation but the premise that because something hasn't yet happened means that it won't or is unlikely to in future is flawed logic.

 

JP

[cuthound]

Don't usually read the Mirror, but read a copy today.

 

This article on "snowflake students" and the younger generation attitude to risk assessment caught my eye.

 

http://www.mirror.co.uk/news/uk-news/thou-shalt-grow-up-not-9327313

 

Seems the younger generation are scared of their own shadows.

 

Edited for autowrong.

Edited November 25, 2016 by cuthound

[Mike Todd]

As I touched on in an earlier post, exactly how dangerous is swimming in an full lock? (Genuine enquiry). If the kids are harried from pillar to post and not allowed to do anything involving exercise or fun, they will run out of things to do and places to go. Alternatives include staying at home and dying at an early age of obesity, and hanging around the town centre mixing with undesirables. I'd never consider swimming in a canal, and neither would my children, but that's not the lifestyle of these children. You could say they have applied their own crude risk assessment, as they have been swimming here regularly with no problems until a non-swimmer decided to jump in.

The water in the lock is at least as unpalatable as in the rest of the canal (where does it come from?) One of the larger risks is said to be infection as a result of ingesting canal water.

 

Also, locks often trap less than pleasant detritus, some of which itself is a hazard to those who encounter it.

[PaulG]

I wasn't trying to compare the risk in the direct sense merely demonstrate the logic as to why a mitigation may be applied to a place that has no history of a particular outcome but not to one that has. For an organisation like CRT reputational risk will weigh heavily into the calculation of risk profile. That's another factor that may have influenced Worcester Bar. Without knowing the logic or even if has been applied equally to both locations I couldn't comment on whether CRT have got it right so I am not disagreeing with you.

 

The argument that 'it hasn't happened before' isn't a good one in making risk decisions. Past evidence certainly features in the calculation but the premise that because something hasn't yet happened means that it won't or is unlikely to in future is flawed logic.

 

JP

I think we actually agree about most things...

However, I was not using the "it hasn't happened before, so it won't" argument.

But of course In any risk assessment you must assess the level of risk.

 

The fact that many people are known to have jumped the canal at WB without serious injury is indicative of low risk. This is not the same as no risk.

 

An event that results in death or serious injury is indicative of the highest level of risk.

 

I didn't intend to get into a discussion of the H&S aspects of the two sites. I accept that there may be perfectly valid reasons for different approaches.

 

However, as an outsider that is not privy to CRT's assessments of the two sites,it does look inconsistent to me.

[Guest]

Don't usually read the Mirror, but read a copy today.

 

This article on "snowflake students" and the younger generation attitude to risk assessment caught my eye.

 

http://www.mirror.co.uk/news/uk-news/thou-shalt-grow-up-not-9327313

 

Seems the younger generation are scared of their own shadows.

 

Edited for autowrong.

Can't say I saw much evidence of this when working amongst a sample of 1000 of them for almost 20 years! I would suggest that they are little different to my generation when we were their age.

[Captain Pegg]

But if you look at a map you will find that Lock 62 (alleged culprit) is relatively away from housing and more rural.

 

Also, IIRC, the locks at the Leeds end of L&L that are supervised are also relatively rural.

 

The lock above Reading that attracts macho teenagers is also away from housing.

 

If you attend to my earlier point about think things through you might see that rural locks may be greater risk than urban ones just because there is less probability of someone being around to help. Also there may be greater difficulty in emergency services being able to get there.

 

The simple fact is that all locks have risks, as does every stretch of a canal. What is at issue is what is a reasonable or proportionate response to each risk. Few people think that erecting notices actually reduces risk in the sense of modifying behaviour. Sadly, all too often the reason notices are put up is so that post hoc the risk 'owner' can then say that they are not at fault and cannot be sued.

I thought PaulG attended to your earlier post very well. I have to admit I didn't read past the first paragraph as I thought it patronising.

 

The issue of someone being available to help someone who is in danger and unable to help themselves is a concept I have encountered in a very significant risk study in my day job. However to make a decision based upon a counter intuitive argument requires some weighty evidence behind it if the person who ultimately has to make and be responsible for the decision is going to use it. Without such evidence to support it is simply a premise and the logic alone shouldn't be sufficient to influence the outcome.

 

So if you could demonstrate that in a study of a meaningful number of incidents of people getting into difficulty there was a significant success rate in effecting rescue then it could start to factor into decisions. Unfortunately in the case concerned the presence of three companions and two passers-by was ultimately not of assistance. It is possible that had the victim been able to stay calm he would have been rescued. Human behavioural factors are one of the more difficult aspects of risk evaluation and usually one that needs specialist input.

 

The effectiveness of signs is in the human factors domain and there is some evidence in my experience of unexpected outcomes. However I do feel it necessary to point out that nowhere in this thread have I stated a personal view that CRT need to take action including the erection of signs. My point in response to those who seek to criticise the mother and coroner is that there appears to be a consistent theme from the other parties concerned - who do have the added advantage of having heard and studied all the evidence - that CRTs response has been lacking in terms of their engagement.

 

JP

Edited November 25, 2016 by Captain Pegg

[dmr]

As I touched on in an earlier post, exactly how dangerous is swimming in an full lock? (Genuine enquiry).

 

I reckon that swimming in a full lock is relatively safe as long as you can actually swim well and are not alone. Rat wee disease is a very small risk in most places but the swimmers do need to know what to do if they become unwell.

However......

My own observations suggest that swimming in a lock on a hot day usually involves a certain amount of showing off to the girls, a barbecue and at least a bit of alcohol, and these increase the risk. Its still probably a whole lot safer and healthier than many of the alternative entertainments.

 

................Dave

 

...............Dave

[Dave_P]

Thanks Dave - I hadn't considered the security aspect. And to answer your question, of course it should be both.

However, IMHO there is a big difference between a perceived risk and one that has been proven to exist.

 

I still think that the two examples show an inconsistent approach.

 

At one site, many people are known to have jumped the lock. No serious injuries resulted.

At the other site, the number of "jumpers" is unknown, but two people have lost their lives.

 

One site gets a sign, the other one doesn't.

Whether signage actually does anything to improve H&S, of course, is another issue..

I suppose it depends on what you class as serious. Being rushed to hospital in an ambulance is fairly serious I'd say. Also, put yourself in the position of a trip boat steerer, passing through the bar many times a day and having people people leaping across the canal in front of your bow.

 

CRT also have to consider what the fall-out would be if someone was drowned in the bar under the hull of a trip boat. Yes, a drowning is equally tragic in all cases but the public/press outcry would be far louder. I'm not justifying it, just stating the pressure CRT are under here.

[Jess--]

Coroners can often make ill informed criticisms, a good example that springs to mind is 2 incidents involving identical fairground rides where a person working on the ride was killed by a moving steel arm (roughly 10 tons).

 

In the first case the person was squashed between a floor plate and the arm, the coroner stated that the floor plate should have been removed to allow enough clearance below the arm for a human to escape harm and that the ride owner was negligent for not having removed it.

 

In the second case the person was killed after they stuck their head up through a removed floor plate and the coroner stated that the floor plate should not have been removed and the ride owner was negligent for removing it.

 

My own personal take was that both should have been prevented by common sense, don't get in the way of a 10 ton arm (there will only ever be one winner)

[furnessvale]

 

 

 

I am disappointed with the coroner here, as the comments seem to represent a general shift in attitude from coroners, who now see their function as primarily to exonerate anybody who may have contributed to their own death by foolishness, and transfer that blame to some authority.

 

I am sure they see this as a valuable public service, and that they are helping the relatives, who probably blame themselves, by giving them a new reality in which a scapegoat has been found. The trouble is that making relatives feel better is NOT what they are there for.

 

Coroners have been doing this for years.

 

As an engineer on the railway in the late 1960s I was involved in a number of deaths on the railway. Coroners were most reluctant to bring the obvious suicide verdict but would leave it open or even accidental, to avoid upsetting the family.

 

Fine, but that immediately left the insurance company open to paying out and in some cases led to cases against the railway for negligence.

 

George ex nb Alton retired

Edited November 25, 2016 by furnessvale

[IanD]

It's perfectly reasonable to say that risks should be assessed.

 

It's not reasonable to say that if a risk exists "Something Must Be Done" (signs, barriers, closing all canals, banning cars) -- in many cases the result of a risk assessment can (and should) be that the risk is small, exists in too many places to be fixed, is widely understood by the general public, and that therefore nothing should be done about it.

 

The fact that somebody died is sad but should not force an inappropriate knee-jerk reaction (unless you're the Daily Mail) -- people die every day from all sorts of causes. About 100 people every year in the UK die by falling out of bed -- does this means that all beds should carry "Danger" warning signs? They ought to, they kill about 100x more people than lock drownings...

 

https://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2011/10/28/Factfile_deaths_large.png

 

Hazards exist in normal everyday life, in the home and workplace and driving and many other places -- the world cannot be made perfectly safe. Ones which kill or injure a lot of people are rightly subject to regulation about protective measures and warning signs. Ones which don't aren't. Let's keep it that way.

Edited November 25, 2016 by IanD

[Horace42]

Speaking for myself I did many stupid things as a kid, and some as an adult. These stupid mistakes have been part of my learning in life, and have taught me much. Thinking back, many of them could have ended in disaster. I doubt if this is a unique position.

Ditto.

 

Not unique at all. I echo everything you said with bells on.

 

I was indestructible. Then I got to 30 and began to believe that perhaps I wasn't immortal. Then as time moved on I knew I wasn't

Yes and in my youth - looking back, the things we did were stupid, but only realising it now - made worse by the fact that we ignored warning signs and knew were also disobeying orders of parents teachers and the local policeman - remember him - helmet, truncheon, whistle, bicycle - and a clout round the ear if caught - and another clout round the ear from your parents if they found out.

We were not bad or wicked - just kids being kids and lucky to survive - unlike this lad that drowned - just incredible bad luck - nobody should reproach themselves - unless in their own hearts they think there was something more they could have done about at the time to prevent it happening.

Edited November 25, 2016 by Horace42

[PaulG]

I suppose it depends on what you class as serious. Being rushed to hospital in an ambulance is fairly serious I'd say. Also, put yourself in the position of a trip boat steerer, passing through the bar many times a day and having people people leaping across the canal in front of your bow.

 

CRT also have to consider what the fall-out would be if someone was drowned in the bar under the hull of a trip boat. Yes, a drowning is equally tragic in all cases but the public/press outcry would be far louder. I'm not justifying it, just stating the pressure CRT are under here.

Dave - I really think that we are at cross purposes here.

I have never said that the notices at WB are unnecessary or unjustified. If I gave that impression then it was unintentional.

They were evidently placed for perfectly valid reasons..

What I said was there is apparent inconsistency in the approach of CRT in that signage was installed at one site, while it was not at another where similar activities were carried out with fatal results.

[Mike Todd]

I thought PaulG attended to your earlier post very well. I have to admit I didn't read past the first paragraph as I thought it patronising.

 

The issue of someone being available to help someone who is in danger and unable to help themselves is a concept I have encountered in a very significant risk study in my day job. However to make a decision based upon a counter intuitive argument requires some weighty evidence behind it if the person who ultimately has to make and be responsible for the decision is going to use it. Without such evidence to support it is simply a premise and the logic alone shouldn't be sufficient to influence the outcome.

 

So if you could demonstrate that in a study of a meaningful number of incidents of people getting into difficulty there was a significant success rate in effecting rescue then it could start to factor into decisions. Unfortunately in the case concerned the presence of three companions and two passers-by was ultimately not of assistance. It is possible that had the victim been able to stay calm he would have been rescued. Human behavioural factors are one of the more difficult aspects of risk evaluation and usually one that needs specialist input.

 

The effectiveness of signs is in the human factors domain and there is some evidence in my experience of unexpected outcomes. However I do feel it necessary to point out that nowhere in this thread have I stated a personal view that CRT need to take action including the erection of signs. My point in response to those who seek to criticise the mother and coroner is that there appears to be a consistent theme from the other parties concerned - who do have the added advantage of having heard and studied all the evidence - that CRTs response has been lacking in terms of their engagement.

 

JP

I am sorry that you found "But if you look at a map you will find that Lock 62 (alleged culprit) is relatively away from housing and more rural." patronising. I was responding to #99 in which it was suggested that rural locks were less risk. I was pointing out that the lock in question is relatively rural.

[Dharl]

Perhaps CaRT should consider renaming this lock for Rafael Pizzaro as a memorial. A description of the accident might act as a warning to others?

fully agree and think this would be fitting way that would honour this tragic accident as well as act as a warning to others on the danger of water.

 

All aspects of water can be dangerous and you should have a healthy respect for it and know your limits, no matter if you boating, swimming or even walking close to it. (Walking close to a heavy sea during a storm and risk of getting carried out to sea...?)

[Captain Pegg]

I am concerned that you are tacitly concurring with the assumption that some locks are a higher risk (in a material way) than others just because of the surrounding social area. There is much danger in going down that route and my risk assessment is that you avoid it.

 

 

That's the bit I was referring to Mike. Maybe the last sentence was humour or irony but I didn't read it that way. I also absolutely disagree with the point you make though. That may have coloured my view of its wording.

 

I see the rest of the post has good examples in it now I have read it.

 

Jon

[PaulG]

I am sorry that you found "But if you look at a map you will find that Lock 62 (alleged culprit) is relatively away from housing and more rural." patronising. I was responding to #99 in which it was suggested that rural locks were less risk. I was pointing out that the lock in question is relatively rural.

I did not make that suggestion at all.

For the sake of accuracy, in post #99 I said "Some rural locks are in the middle of nowhere, and are therefore low risk."

Different thing altogether.

Edited November 25, 2016 by PaulG