Learning from Safety Incidents and Case Studies
Safety Spotlight
Welcome to an area that will be updated periodically to cover some notes on general themes that we have encountered and a spotlight on some case studies to aid learning and development.
Please use this page and the case study downloads with your teams.
December 2024 - General Themes
Active Games:
Active games cover an array of activities, at different paces and using different equipment. Planning for each activity is important to ensure risk assessments have identified hazards and controls, and timely communication to members and their parents/carers. This could include bringing extra equipment such as a torch for night activities or a gum shield option for indoor hockey.
Dynamically risk assess every time and remember to stop the activity at any point you think it is unsafe. If you highlight further controls, make a note and update your risk assessments for the future.
Terrain and Environment 0:
Terrain/Environment 0 does not equal 0 risk. Check out some top tips for planning terrain/environment 0 activities:
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Do a pre visit to identify any hazards (Such as water safety if you are cycling along a canal)
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Do check levels of competence of members and volunteers
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Do follow best practices recommended
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Do communicate with you Volunteer team: the plan, the risk assessment and emergency procedures
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Do dynamically risk assess as the activity is taking place, alter and stop where necessary
Supervision:
Keeping members safe while allowing them freedom can be challenging to balance. We see many incidents occur when members are on free time. Adequate supervision and controls should be considered for each activity, the environment and the members supervising.
December 2024 - Case Studies
Check yourself:
As a Volunteer or Leader in Charge, it is too common for people to forget to be belt and braces with their own safety whilst they are looking after everyone else. As an activity leader, do you take the important extra time to check your set up before abseiling or check your PPE is on correctly for example. Remember it is always the most important thing to keep yourself safe so you can continue to look after the members you are supporting.
An Activity Leader was taking a group of 5 abseiling on a natural cliff face in fair weather. The Activity Leader had an assistant, and the group were accompanied by another two volunteers. One of these volunteers was also a parent. The Activity Leader was the only person regularly using this location for abseiling, and only person suitable qualified to run the activity. All adults were positioned at the top of the crag during the session. There was no safety barrier at the top of the crag.
All member of the group had abseiled down once and were on their second go. A member froze part way through the abseil and the Activity Leader had then lowered him down manually, the member became distressed as they could not undo their safety line. A volunteer was becoming distressed at the top of the crag and had approached the edge on several occasions. The Activity Leader had asked the Assistant to walk the short path (2 minutes) from top to bottom to support the member at the ground. Whilst waiting for the assistant to reach the bottom, the Activity Leader decided to abseil down to the member instead using the abseil line only. He fell from the top of the cliff narrowly missing the distressed member, resulting in multiple life affecting injuries.
Risk assessments and operating procedures were in place but branded by the Activity Leaders professional company and not location specific. All equipment used was owned by the campsite that the incident occurred.
The members screamed and ran away, a volunteer with a medical background stumbled and fell on the Activity Leader when treating them (so was asked to leave). The group reported to not have received emergency procedure briefing before or on arrival, these emergency procedures were also not accessible.
The incident response was led by a Deputy Site Warden and involved coastguard, mountain rescue, ambulance and police services. It was reported to HQ by email the same evening and by telephone the next day.
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Most critical incidents are a result of a multitude of smaller contributing factors, can you identify some of the contributing factors? This can be known as lining up the lemons.
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What could have been done differently?
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When attempting to manage several factors at a time, what human performance tools can you or do you use?
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What risk assessment and emergency procedures should be planned and communicated ahead of time?
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When and how should critical incidents be reported to HQ?
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The Activity Leader should take responsibility to identify, brief and deploy other volunteers to appropriately to support the safe delivery of their activity.
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Leader of any activity should identify and use the least risky method of solving a problem. This is the application of good risk assessment practice, both written and dynamic, that identifies those options with least risk.
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Volunteers and activity leaders should follow best practice in line with assessed external standards for each activity.
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Emergency procedures and group planning should have considered how young people not directly involved in an incident are best supported.
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All leaders and volunteers should be informed of and understand the emergency procedures prior to the start on any activity or camp.
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Emergency Procedures should identify and state the best ways of communicating location to emergency services, being mindful of where the nearest access points to the location are.
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A scouting risk assessment must be completed prior to any activity taking place. Executive committees must understand their responsibilities including when it is appropriate to use commercial businesses and their risk assessments, as stated in POR.
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Scout units offering adventurous activities need to be clear and not mix the rules and procedures when these are provided by in house scouting volunteers or external commercial companies.
Environmental Hazards:
Weather has changed somewhat over the years which also changes some environmental hazards. Trees are more prone to diseases and sudden limb drop. Ticks are much more abundant with reports of people with up to 60 ticks requiring A & E removal. Sun burns and heat related cases also seem to be on the rise.
Prioritise time to make sure you are familiar with environmental hazards pre, during and post activities. Be up to date with advice. Share this advice with members and ensure that it isa priority throughout.
An Explorer Scout was critically injured sitting on a bench on his own in the dining shelter at a county-owned campsite when a tree branch fell approximately 12m directly on to them.
The Police and HSE attended the incident and declared a crime scene, with witness statements being taken from site manager, volunteers and members.
Alternative accommodation was provided by the campsite, and the camp was taken down the next day following an agreed safe system of work to recover the camping equipment.
The site had a tree survey undertaken 6 weeks before hand. The tree which lost its branch had been identified for felling with the recommendation of within 6 months. The tree required a tree felling licence from the forestry commission and the site had started the process of getting this work commissioned with the aim of it being completed by the end of the summer / early September which would be within 4 months of the tree survey.
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Was the risk of falling trees/branches on the risk assessment for the group/site owner?
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How could you identify environmental hazards on arrival to update your risk assessment i.e. ‘look up’ & how would that affect your plan to set up camp? Be curious - what questions might you ask when seeing marked up trees (coloured dots)?
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Is sufficient emergency planning in place for an incident of this nature/occurring on a campsite away from home?
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How robust is your InTouch system? Would you be dependent on network coverage (OSM)?
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How would you deal with the remaining members & their welfare in an ongoing incident?
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Ask for a site safety briefing/exchange of information & carry out a hazard check prior to setting up camp; record this on your risk assessment
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Site owners must follow tree safety guidance thoroughly – zoning, labelling/images, inspections & ensure works are carried out according to zones i.e. higher risk areas are prioritised & progressed
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Ensure all leaders are familiar with the requirements of the Purple Card to speed up assistance, particularly in terms of media, legal & financial. Ask for what you need i.e. taxi was provided to return the lead volunteer from hospital
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Look after each other – provide mental health resources & undertake welfare post event
Stoves:
There are a wide variety of stoves and different fuels on the market for cooking, but how much do we know around the different hazards of each of these? Such as methylated spirits are highly flammable and create a flammable vapour at temperatures between –11 and 13°C. Check out our Stove Resources and Case Study to familiarise yourself more about each type.
During a cooking activity with a group of scouts in a campfire circle, several cooking bases were set up, utilising various techniques and skills for lighting fires. This included the use of a penny stoves, dragon stoves, and open flame fire.
During the activity, one of the penny stoves went out and could not be relit. The penny stove was located within a fire pit, where a dragon stove was also used to boil water. The leader, after two failed attempts to light the penny stove, decided to replace the stove with another one. The replacement stove was placed in the same location and refuelled with methylated spirits. The leader moved away from the fire pit area to place the methylated spirits bottle on the table and then returned to light the stove.
Prior to being light by the leader, the vapours created a flash flame which caused burn injuries to one of the scouts involved in the activity.
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Camp firepit layout – was their sufficient space between the stove and other sources of heat?
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Familiarity – how experienced was the volunteer with this specific type of stove?
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Understanding of the flammability of methylated spirits – was there a good understanding by the volunteers that methylated spirits (meths) is highly flammable and can create a flammable vapor at low temperatures (-11 to 13°C) which can ignite causing a fire ball.
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Was the warm stone/brick (the base of the fire pit where the previous penny stove was situated) a contributing factor to its ignition?
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Was the use of the meths bottle (without a safety valve) a contributing factor in the amount of meths poured into the penny stove?
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Only use one stove per fire pit.
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Undertake training and be familiar with the stove in use. How to use a meth burning stove safely | Scouts FS120348
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DIY stoves, often known as Penny Stoves, or Soda Can stoves are not recommended.
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Consider using alternative stoves – some ‘Trangia’ stoves are adapted to use gas.
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Use a fuel bottle with a safety valve.
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Wear appropriate clothing when using stoves (no fleece or nylon clothes to be worn).
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Ensure the stove, the burner and surrounding area is cool before attempting to re-light the stove.
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Pre-plan emergency access and know W3W (What 3 Words) or GR (Grid Reference) before the event. All volunteers involved in the event will play a role in the emergency plan if activated.
Emergency Procedures:
If an incident occurs, quick and timely medical intervention is necessary. Always stay familiar with the emergency procedures for each activity. Consider:
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What information do you need to share with emergency services?
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What is the best access to the venue? E.g. having a what three words reference to access to a site at the right location?
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Sending people to meet emergency services
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Locations of medical forms and emergency contacts
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Locations of first aid kits
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How are the other members going to be managed
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Reporting to relevant people (HQ, external organisations etc)
At the end of an activity day at a Scout-run campsite, the activity leader for the abseiling tower chose to abseil down the tower without proper safety precautions in place. This resulted in them letting go of the abseil rope halfway down and falling 12 feet to the ground.
Immediate first aid was administered, but there was confusion with the 999 operators regarding the exact location of the site, causing a slight delay in the arrival of emergency services.
The injured activity leader sustained multiple injuries, leading to a prolonged period of hospitalisation and recovery.
Limited knowledge of local contacts for escalating the incident meant that key individuals, such as County and District Lead Volunteers, were not informed until several days after the incident. This delay hindered vital local support for the injured activity leader and those who provided first aid.
This was the third such incident at the campsite in a short period, all potentially due to operator error. Local practices had not been formally reviewed or independently checked for a prolonged period of time.
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How frequently are the trustee board and leadership team reviewing local incidents and reports to reduce the likelihood of similar incidents in the future?
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Is there clear signage with multiple references to the postal address, What3Words, and grid references for the site, especially in areas where significant injuries could occur, such as climbing walls and swimming pools?
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Do your volunteers know how to escalate an incident locally through the lead volunteer line management chain?
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Is your first aid equipment available and accessible in the event of an accident or emergency?
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Do the first aid kits include items for injuries identified in the activity risk assessment?
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How recently have activity leaders and instructors completed their Continuous Professional Development (CPD) to ensure they have the most up-to-date practices, knowledge, and information to deliver safe activities?
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Ensure local processes are in place so that activity leaders and instructors understand the required Standard Operating Procedures (SOPs) and risk assessments for the activity, including any updates, before leading the activity.
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Review the climbing and abseiling setup to ensure that safety equipment, practices, and procedures are in place to keep activity leaders, other volunteers, and young people safe.
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Ensure that activity leaders and instructors are sufficiently trained and have maintained their CPD to demonstrate up-to-date good practice, skills, and knowledge in the activities they deliver.
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Conduct regular, objective reviews of safety incidents and accidents to identify areas for learning and improve local practices and procedures.
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Ensure sufficient, inspected, and in-date Personal Protective Equipment (PPE) is available for the activities being delivered.
Keeping people safe on assessment:
Assessors are responsible for the safety of everyone during any training and assessment. Activities where the candidates are asked to demonstrate certain skills needs to be carefully managed e.g., lead climbing, leading a group of paddlers down a rapid, leading a group on steep ground, leading a mountain bike group on an off-road single-track trail etc. Assessment can often create extra psychological stresses and heuristic traps. Ensure you are creating progressive assessments towards the standard, to evidence candidate competencies before they are participating in a higher risk activity. Find out more about ways you can keep your candidates safe on assessment through our case study.
During the first day of a RDCI Assessment the candidates were taken to a slate crag, with limited climbs at the grade required for the qualification. It had rained the night before and was an overcast day with showers forecast. 4 climbers were asked to complete a lead climb there was only 1 climb at the grade, and another climb the grade above. After 2 climbers had completed their lead, a heavy downpour occurred, and the climbers took shelter. After the rain had stopped the climbers returned for the second pair to lead. The injured party climbed the route that was at the grade, they had placed 4 pieces of protection, and upon clipping their fifth, fell off. All the previous protection came out and the injured party hit the ground. This resulted in multiple fractures and open wounds. Emergency Services were contacted, and Mountain Rescue were first to arrive 30 minutes later.
It was established that the Course Director was not a member of a professional association. The injured party had not got the breadth and depth of climbing on this rock type or leading beyond this grade.
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How could you check the currency and accuracy of experience of candidates?
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What things can influence performance and decision making on assessments?
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How could you reduce heuristic traps during an assessment?
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How could this relate to other adventurous activity assessments?
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How could you get peer support as an assessor?
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Dialogue advance of the course checking the currency and accuracy of the experience of the member.
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Recognise the psychology of candidates on assessment feeling the pressure to perform. This may include peer to peer ‘benchmarking’ and influence, and a misunderstanding of the standard and purpose of the activity.
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Continuous open and transparent dialogue with the candidates outlining the nature of the activities and identifying the importance of sharing concerns or uncertainty immediately.
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Ensure that the assessment is progressive and build up the day towards the assessment grade/standard. Identify ways in which you can put candidates at ease whilst demonstrating the skills and therefore as an assessor build up your knowledge and evidence of their competencies. E.g., Consider a ‘warm-up’ route or a top-rope exercise before assessing lead climbing.
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Be aware of the commitment trap when the conditions are not favourable. You should always be prepared to change the plan, venue, tactics, dates, or even cancel the assessment etc.
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Be aware of the scarcity trap when choosing a venue with limited options. You may end up doing something you are not comfortable with – just because it is now your only choice or chance.