Lessons from the Drowning in Morses Pond

Wellesley

Wellesley (Photo credit: be11boy)

On 1 June 2013, my kids, wife and I were on the beach during the drowning of a 10 year old boy. This happened at Morses Pond in Wellesley, Massachusetts, the first drowning there in 38 years. The kid was found after 1.5 hours by a Fire Dept diver in waist high water, 30 feet from the beach. He was taken to the hospital but was pronounced dead shortly thereafter. Everyone’s question is: could this have been prevented? My answer is maybe, if leadership from below had been allowed.

I do not blame the lifeguards. The eight lifeguards I saw conducting water rescue were professional. I do not blame the first responders, police, firemen or AMR. I do not blame the Wellesley Town recreation department or indeed anybody else. I do not blame parents or the drowning victim’s caretakers. This was a tough situation, but nevertheless one we need to learn from.

I want to start a debate about the risks of letting our kids and youngsters swim and play at Morses pond. I also propose to change the Emergency Action Plan (EAP) and missing person protocol at Morses pond to allow for volunteer efforts, in and out of water. Furthermore, I think that authorities, large and small, should listen to good ideas, regardless where they are coming from, even in a stressed situation.  This is simply good practice.

Resident rescue idea rebuffed

When we all heard on the loudspeaker that they were looking for a kid, I ran to the head of the lifeguards and said that we should get together all able adults, form a human chain and walk systematically out from the beach until we reached our waist. This is common sense. It is a good idea. It has been tried in many, many rescue operations. It usually works, too. And, it is not dangerous. That would enable lifeguards to conduct a search in deep, less accessible waters.

Chain of Command 

Unfortunately, my request was denied. The Wellesley recreation department staff in charge said it was against their Emergency Action Plan (EAP) and missing person protocol: “Everyone out of the water. Pull back.” As it was immediately apparent to most of us on the beach that this protocol was not working, I pleaded him to break protocol, but to no avail. I then turned to the Wellesley police who had arrived at the scene and asked if he could authorize this maneuver. He was at least willing to listen to me, but then turned me down. Perhaps he felt that the matter was being handled by the handful or so lifeguards in the water already. Besides, from what I understand, the day before a kid had been missing, too, and he was found playing nearby, so false alarm. Also, perhaps the fact that there has not been a drowning at Morses Pond in nearly 40 years played a role.  I now have to live with the knowledge that my idea might have led to getting the 10-year old boy out of the water within 15 minutes as opposed to 1.5 hours and that I did not carry it through.

I am emotionally distraught just thinking about the fact that a life potentially could have been saved and also that I did not get a chance to help. We were dozens of adults who stood on the beach helpless, without being empowered to or allowed to have any role in the rescue. I am sure those of you who read this and who have kids will understand: this was a terrible experience. I ran around the beach searching for a while, but gave it up; the instinct said the kid was in the water. Then, I took my kids home to save them from what was to come.

Situational expertise

My experience from rescue situations, on water, snow or in forests is that manpower intensive, systematic search is the quickest and best. The last time I saved someone from an emergency was when I helped 20 people out of a burning bus I myself was on in a Sicilian tunnel in Southern Italy. Again, we formed a chain of hands and got people out through a 1-mile long tunnel.  From the media, I have read that a similar thing happened during a near drowning incident on a New Zealand beach a while back. A human chain stretched out to the reef in high waves, think about that for a second.

I grew up in a place surrounded by (cold) water and where water safety was paramount. All know how to swim from an early age, safety equipment is abundant and water safety is a mantra. Yet, even there, accidents happen regularly. I have practiced all kinds of rescue scenarios as part of army drills on water, ice, and land. Moreover, I am an intuitive thinker under any circumstance. I also teach strategic management. I am not sure how many on that beach had similar experience, possibly a few, but I do know that most adults know how to swim and 100% of them can march into water until their waistline. Walking in water does not put any additional lives in danger.

Experience from rescue situations in water, as well as common sense, shows that time is of the essence. For kids under 12 in 70 degrees Fahrenheit water temperature, most experts  estimate one has 2-3 minutes before full loss of consciousness,  5-10 minutes before brain damage, and 15 minutes before irrecoverable death. However, if the body goes into Mammalian diving reflex and shuts down to conserve resources, which mostly happens in cold water and with smaller kids, in rare cases, one has 30 minutes or even more.

Beyond lifeguards

Placing three 16-year old lifeguards at the beach is good for directing general beach behavior. However, as a life saving device, it perhaps also creates a false sense of security which in itself is no service to parents. Nor is it a service to the teenagers themselves since it places too much responsibility on young shoulders. This is no swimming pool. The water is not clear. There is very little chance that any lifeguard, however experienced, would be able to guard all swimmers, much less find one missing child, especially if there are more than 100 people in the water on the first real beach day of the season, which was the case that day. Parents and the Wellesley Recreation Department should realize that having lifeguards on the beach is good but not enough.

Managing the Unexpected

In Managing the Unexpected (2007), Karl E. Weick and Kathleen M. Suthcliffe explain that high reliability organizations, such as ERs or firefighting units (and, generally, trained lifeguards), do not defer to experts but to situational expertise, including common sense, and always allow ideas to flow to the top, even under duress. When life is at risk, qualitative, subjective input is more efficient than the chain of command. Such organizational units are flexible in crisis, not rigid.

In management theory, there is now a growing acceptance that making good use of networked relationships matters. Leadership from below, where ideas and contribution comes from people who may be outside the formal chain of command, can be a fruitful addition to the insistence on hierarchical authority and narrowly interpreted protocols. When such leadership initiative is put into a system, tapping into the flow of ideas that exist and building core capability from the ground up, the organization can be said to have a strategy from below, and becomes highly advanced, agile, and resilient. Only such organizational designs, obviously empowered by generally sound emergency procedures, should be trusted in emergencies.

Principles for parents

Every year, nearly 1100 US children between 1 and 19 years drown. Male, younger, epileptic, and unsupervised children are considered at greater risk for drowning. However, the much quoted SAFE KIDS study examined data from 496 child-drowning deaths from 2000 and 2001 from 17 states and found that 88 percent of the drowning victims were under “supervision”. Moreover, a recent article by Morrongiello (2013) in the journal for Accident Analysis & Prevention claims parents overestimate the effect of swim lessons on lessening their child’s drowning risk. Parents erroneously believed that children could save themselves from drowning by the age of 6.21 years. Considering this statistic, the recent article, and the Morses pond drowning, I would like to offer up for discussion some principles for parents.

  1. First off, if you bring kids to the beach you are their lifeguard: this means you keep two eyes on them at all times and ideally come in the water with them and stay on the deep end. There is no sense in outsourcing the primary responsibility of taking care of your kids.  Ideally, you bring your own flotation device into the water with you.
  2. Secondly, do not let kids who cannot swim play in the water if there are many people around. You cannot control the environment. You could create a situation where they get scared of water and will never learn to swim.
  3. Thirdly, do not let your kids play alone. Regardless of age, instill in them the need to always swim with a companion.
  4. Fourthly, if there ever is another incident where a kid is missing; please let us join forces, ensure all other kids are safe and then, with the authorities’ blessing of course, let us proceed with massive manpower to comb the beach in a human chain. Let us walk out together with as small of a space between each person as possible, not to miss an inch of beach. Let us walk towards those authorities hand in hand and open their mindset. No fear of legal repercussions should stop the community from trying to save a kid.

Any set of rules, even emergency protocols need to be applied with common sense. An emergency protocol which was created to deal with a swimming pool like scenario where the lifeguards would have some degree of probability of protecting their swimmers cannot be applied pre-season when the protective rails which usually are in place are not there. Nor is a “missing person protocol” the same as a a “near drowning scenario”.  What complicates the matter is that, at a beach, we almost always have to assume that a missing person means a near drowning person.  Making the distinction between a missing person and a drowning person is crucial.

The area in and around Morses pond beach is simply too vast for a few lifeguards to cover in such an emergency as we saw on Saturday. Strategy from below, which is an efficient way to think about management, means to take a good look at the total resources available to you before making a decision and running blind with procedural delight. Lifeguards alone cannot make a difference. But, again, hindsight is 20-20. What matters now is the future.

Needed upgrades

My suggestion to the town of Wellesley Recreation department and to those responsible for the safety of residents and visitors to Morses pond beach, including lifeguards, is simple: let Wellesley residents be part of systematic emergency drills at the beach. Train all adults present on the beach, every day, in the practice of forming a human chain to quickly comb the beach. The existing Emergency Action Plan (EAP) must be thoroughly examined including by outside, neutral parties with operational pond safety experience from near drowning searches.

Beyond that, here are some further recommendations:

  • Beach management should raise awareness of pond safety by handing out safety flyers to each entrant and pay particular attention to making non-residents aware of the conditions and regulations.
  • Establish a pond safety committee where residents are included.
  • Require consent forms where swimming ability is included.
  • Do not open the beach pre-season. All equipment and procedures need to be practiced and ready each season.
  • Improve the fencing outside the beach zone and better delineate the safe area where lifeguards are in charge and specify the hours they are on duty.
  • Update the emergency equipment on site also seems necessary: warning signs, buoys with 20 ft ropes, 12ft poles with sweeping hook, life jackets and flotation devices every 50 feet along the beach, rescue boat, emergency sonar and water binoculars, to name the basics. I am sure Wellesley residents who use Morses pond would help pay for these expenses, if necessary.

I would not reopen the beach until these things are in place.

When the minutes matter, we cannot rely on a few lifeguards who have to look through a vast area of murky water. We also cannot wait for a diver who needs to be alerted by a 911 dispatch, needs to get his equipment together, drive to the scene and get his bearings. We need to act, then and there, with all the equipment and manpower we have then and there.

 

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About trondau
Trond A. Undheim (39), Ph.D., a Senior Lecturer at MIT Sloan School of Management, and Managing Director of Tautec Consulting, has over fifteen years of multi sector experience in strategy, policy, communications, academia, and entrepreneurship. Formerly, he was a Director of Standards Strategy and Policy at Oracle Corporation, with wide responsibilities in long-term business development, strategy, public policy and standardization globally and in Europe. Trond is an executive, speaker, entrepreneur, author, traveler and blogger. With a doctorate on knowledge work and the internet in Silicon Valley, he is one of the world’s leading experts on technology and society. He has worked at Oracle Corporation, the European Commission, the Norwegian Government, and founded a start-up. He was awarded an interdisciplinary Ph.D. from NTNU, Norway’s top engineering university, as the youngest candidate at the Faculty. He is multilingual and has lived on three continents. He is always ready for strategic opportunities providing significant intellectual and managerial challenges.

4 Responses to Lessons from the Drowning in Morses Pond

  1. Pingback: Lessons from the Drowning in Morses Pond | Trond Undheim

  2. Susan b. says:

    Excellent article but unfortunately the fear of law suites rules over common sense.

  3. Pingback: Wellesley resident urges fresh thinking on emergency action in light of Morses Pond tragedy | The Swellesley Report

  4. Very nice article. I am very impressed. It is both well written and well though out.

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