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?
Done.
Maybe a thread split as I’m sure this is interesting to many. (I know the broad strokes but not the detail)
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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.
Wow.
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 
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.
Wow.
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.
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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.
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I think this applies just as much to those of us doing the approving as it does to those making the submissions. As others have stated I’ve had to deal with a number of WATTO’s over the years who won’t even look at a short notice application because it doesn’t meet the timescales, despite the fact there might be a very good reason for a short notice submission.
I also know a RATTO who refused to authorise an out of season expedition training session for Cadets who were travelling somewhere in the Summer where the conditions would be similar to a UK winter. (It took HQAC to get involved to resolve that).
We not only need to be making sure we are consistent across the country, but we also need to make sure that we are really looking at applications, not just running through a tick sheet of does it have a, b & c. (Although that’s also important)
Does the AT world have an annual conference for all the WATTO’s, Deputies and the RATTO’s in the same way that DofE does? (Being new in post no one has mentioned one?!)Ig would seem to me an ideal way to insure standardisation across the Corps and also to share best practice and build relationships as the DofE one does.
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Absolutely - I didn’t mean to suggest otherwise.
Absolutely agreed - I think some standardised training for WATTOs would be good (particularly for those that don’t actually hold many qualifications)
No, only the National AT panel which is only RATTOs. I have a mind to start up an annual conference over this way for all AT instructors / WATTOs that want to attend, held out of one of the centres, to include standardisation / updates / workshops.
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I think that’s where an annual conference getting us all together would be really good, hell even the WO’s have a conference. It could be run more as a CPD event, depending on what the format is we could even get it counted as a point towards MTA CPD.
From where I sit we seem to going through a lot of personnel changes (1 RATTO retired, another only clinging on as Region didn’t want either of the applicants for the role, certainly in my region 2 or 3 of the 6 WATTO’s are changing or have changed this year).
This is useful reading:
https://ski.utah.edu/feature/addressing-human-factors-in-avalanche-accidents/
it’s got 6 heuristic traps (as @redowling mentioned), and although they focus on winter sports they’re all relevant to any AT activity. I use this resource whenever I instruct on any form of LLA/HML/ML course
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