The Great Orme Incident

You’ve clearly never heard of heuristic traps. This is a classic example of that - familiarity. Just because nothing happened then, doesn’t mean it won’t next time.

I refer you to the Great Orme incident… They just pulled out some maps and cracked on. That went well.

To be fair, It wasn’t the location, or the activity that was the issue. It was the poor group management, and individuals who actively chose to break away from the main group.

IMO That incident could have just has easily happened on the slopes of Snowdon, or anywhere. And crucially, I think that no amount of SMS AT applications would prevent something like that happening to us.

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This is only a couple of the 20 points raised by the coroner; many of the others (such as route planning, risk assessment, appropriate governance processes) are covered by our processes. As this incident demonstrates, just because the environment is perceived as ‘benign’ when compared with the original plan, it doesn’t mean that it is safe.

I don’t for a second believe that the SMS applications necessarily make us safer - that is always ultimately dictated by the people on the ground delivering the activity - but they do encourage people to think about and plan their activities in advance and open them to scrutiny and positive challenge, which is a good thing. You just won’t realise that until something goes wrong and you are having to defend your actions.


I agree 100%. And I speak as someone who has been at the wrong end of a cadet accident compensation claim (although not AT related)!

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Can you enlighten the unenlightened?

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PM’d you the info

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I’d be interested if you can send to also, please?


Maybe a thread split as I’m sure this is interesting to many. (I know the broad strokes but not the detail)


So the reporting of the incident is here:

And the actual prevention of future deaths report is here:

I’m a little surprised this isn’t more well known about, as it’s a good case study as to why we have the systems we do.


Thank you for sharing.

Do you have the full report that included the recommendations that is referenced or was this not published, perhaps it needs an FOI along with the “Cadet David” report.

I think Point 18 is important with the spread of units & hierarchy, much the same us us with a sing policy interpreted 7 times (region & CCF) and then again ~38 times (Wings & CCF Areas) and then a further 900+ times at unit level.

It’s not beyond reality that you have 2 units on either side of a Region border less than 10 miles apart running the same activity with totally different expectations of planning & supporting paperwork.

Which reference are you talking about? The only one I’m aware of is the Prevention of Future Deaths report which is linked above.

I was referring to the comments in Section 8, maybe this is the report, but i thought their might be more :man_shrugging:

That is the report as I understand it.

I think it’s worth pointing out that the Jury were discharged before the end of this inquest, an so there will be a second one (where I understand the Scout Chief Executive will be called to give evidence). It should be taking place about now, but I rather suspect that the current situation has delayed things somewhat.

That’s damning…

Then they are a bunch of renegade toy soldiers.

And yet… you hear the same kind of rhetoric such as ‘why do I need to do this or that, never used to do it in my day’, ‘grab some maps and crack on’, ‘never had a problem before’, ‘it’s only…’ coming from within our own organisation.

The unskilled and unaware combination is a risky one.


Going back to this point briefly - no, it wouldn’t in itself - but it would reduce the likelihood of it happening possibly. It would open up questions about the site specific risk assessment of the route, ensure a written risk assessment, it would force the availability of a nominal roll & contact details… and so on, addressing many of the criticisms raised in that report.

It is entirely feasible that the event would still have been allowed to go ahead in exactly the same format - however the instructors might have gone with a clearer picture in their mind of the site specific risks and the need to implement controls to minimise those risks, as well as a better laid overall plan. If they just threw some old documentation at an application with no consideration of the specific circumstances, got it approved and then gave it no further thought then it is much more likely that a similar incident would occur. This is where it is, ultimately, down to the individual and whether their view of the approvals system is of a ‘tick box’ exercise, or of a useful planning & peer review exercise.

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The unconscious incompetence. A massive human factor that often leads to the biggest issues we have in a lot of industries but is very common among CFAVs and just lately Permanent staff it seems.

An understanding of the Four stages of competence for staff would probably be a good thing to be introduced on ATF courses or MOI so people might understand why some things are the way they are.