Managing risk at aquatic facilities
By Kyle Ryan
If there's one thing the world of aquatics has an endless supply of, it's horror stories. It's not surprising, considering the statistics: There were 99,961 aquatic injuries in 2001, according to the National Safety Council. They range from the usual bruises and scrapes to horrific accidents that cause death or serious injury.
Talking to Dr. Alison Osinski of Aquatic Consulting Services is enough to drive the skittish away from aquatics forever. There was the little boy who had his colon sucked out by a home spa. The man who was underwater in a hotel pool for 18 minutes before anyone found him—or a little boy who spent two days at the bottom of a home pool. They sound unbelievable, but Osinski and numerous consultants who do similar work have a stockpile of these terrible stories, each of them more unnerving than the previous one.
People love water recreation, but that affection sometimes can lead to drowning, spinal injuries, suction entrapment, illness from waterborne disease, electrocution and a host of other problems. The good news, though, is that most events aren't catastrophic—but they still occur. However, with the right preparation, many accidents and injuries can be avoided or at least minimized.
A facility's risk depends largely on what type of facility it is. A splash play area doesn't have the same needs as a local recreational pool, which differs from the nearby waterpark, which needs something else than the beachfront a short distance away. Sometimes, the threats aren't immediately apparent, particularly at waterparks and recreational areas.
"What looks good on blueprint takes a while for the incidents to develop," says Tom Ebro, president of Tom Ebro Water Safety Consultants. "It takes kind of an outcry and a series of these kinds of incidents to occur before the resistance is overcome."
Gerald Dworkin of Lifesaving Resources, an aquatic consulting company, breaks it down to an acronym: HRD. H stands for hazard, meaning a physical object at a facility. R stands for risk, such as the activities that place people at a higher risk. Combining H and R results in D, danger, which managers need to mitigate.
"The classic example is shallow water would be a hazard," Dworkin says. "A head-first entry into the water would be a risk. If you combine that risk and the hazard, namely diving into shallow water, that's a danger."
With all of the inherent concerns involved with aquatics, it's enough to make facility managers wish for a simple pool. But it's possible to manage risk. Tom Griffiths, Ed.D., director of aquatics and safety for Penn State University and creator of the Five Minute Scanning Strategy for lifeguards, says a lot of it comes down to a handful of issues.
"There's three big things you want to protect against: no diving into shallow water, parents please watch your children, and no prolonged breath-holding or underwater swimming," he says. "If you cover those three bases, you've eliminated the vast majority of your risks."
Of course, others still lurk out there, but they aren't that mysterious. What's that expression about the devil you know?
Popular culture has had a surprising effect on people's conceptions of lifeguards. No one mistakes a show like Baywatch for reality, but movies and TV have created this image of muscular, attractive people who typically do everything but pay attention to their jobs. In reality, a lifeguard many times is a bored teenager watching people swim laps and wondering if it'd make any difference if he left.
It would, and it does.
"The best, most desirable way to ensure that there's going to be the best possible protection afforded in a pool setting is the inclusion of a lifeguard within a facility," Ebro says. "You can prove it over and over."
But that bored teenager? He's not the best person for the job. He shouldn't be zoning out, falling asleep, or otherwise distracted from the very real threats that occur in front of his eyes. Although the average lifeguard age is 17, according to Dworkin, they are often younger, and that's problematic.
"The responsibilities the 15-, 16-, 17-year-old kids have is no different from a firefighter's, police and EMS personnel," Dworkin says. "They actually have more responsibility because the firefighter and EMT sits and waits for the alarm to go off, and then they respond. The lifeguard doesn't have that luxury. They have to sit and stand to identify the incident before it occurs and hopefully head it off."
Early last year, the Department of Labor restricted the use of 15-year-old lifeguards, mostly in the amount of hours they can work and where they can work. No one under the age of 15 is permitted to be a lifeguard, but Osinski thinks that 15 is still too young.
"Historically we've had lifeguards at a fairly young age, and I don't think that's a good thing," she says. "You're going to get inexperienced or very young individuals who may not have the maturity or the strength or the skill to do the job. So my recommendation is hire adults, pay them appropriately and provide adequate training."
She concedes, though, that young adults can be a part of a lifeguarding staff that's large and experienced and can supervise young staff members. Dworkin doesn't see it so much as an age issue as a skills problem.
"From our experience, maturity hasn't been the factor—it's been the skills ability," he says. "I mean, you can have a 25-year-old lifeguard who may have barely passed the course and can barely swim themselves, and they've been put into a situation where they're supposed to be able to perform rescues, and they can't. It comes back onto the manager to establish a skills-testing program upon employment."
Lifeguard certifications can be misleading, as the various training methods (Red Cross, YMCA, Starguard, Ellis And Associates, etc.) use different curricula. Red Cross advises lifeguards to get the victims to land as quickly as possible. YMCA suggests in-water activity. Both of the organizations, along with the U.S. Life Saving Association, currently are working on new, universal standards, but things remain complicated now. Even worse, ambitious scam artists easily can forge lifeguard certifications.
"Over the past several years, there have been numerous instances where lifeguards have shown up with forged lifeguard credentials," says Will Evans, director of safety information for Markel Insurance Company. "These credentials were questioned only when the lifeguard's performance and skills were tested and found to be inadequate. If the organization had not performed these skills tests, guess when they would have been tested?"
In the company's aquatics risk-management guide, Markel recommends facility managers check certification records, conduct physical and vision screenings of new lifeguards, as well as offer a hepatitis-B vaccination. With new lifeguards that's when their training should begin, not end. They need site-specific training so they can understand the facility's unique requirements. Those depend on what type of a facility it is—what works at one may not work at another. Once a manager establishes that foundation in a new lifeguard, it needs to be maintained with ongoing training. All aquatics experts agree—vehemently so—that continuing education is critical.
"People forget things," Osinski says. "If you don't drill on this constantly, you forget how to do it…This is something you want them thinking of regularly. You want to make sure they have the capabilities to do the job."
In Markel's guide (available at www.aquaticsafetygroup.com/documents/ Markel_Aquatic_RiskMgmt_Guide.pdf), the company recommends a number of in-service training options, from bag-valve mask and oxygen therapy to victim-retrieval practice to guarding the disabled. The seemingly endless possibilities ensure enough variety to keep staff members interested in new material.
Ebro sees something troubling in part of the lifeguard-training process. It's a matter of focus: Lifeguards have gone from proactive (anticipating and preventing incidents from happening) to reactive (acting when something occurs). When he made an instructional film in the '70s for the Red Cross called Preventative Lifeguarding, he stressed the importance of being proactive.
"It goes through a whole sequence that portrays the lifeguard as someone that is trained not to just wait until something happens but anticipate things that happen," Ebro says. "Go out there and prevent it in the first place."
To keep lifeguards attentive, most experts recommend rotating their position frequently. Griffiths' Five Minute Scanning Strategy aims to keep them alert by changing their mental process every five minutes. Even moving to a different position around the aquatic area will help. Sitting in one place essentially in one position for extended periods of time only encourages distraction.
Even though a well-trained and attentive lifeguard is the best prevention against accidents, some places simply lack the funds or resources to have one. In these cases, lifeguard substitutes in the form of "water watchers" or attendants can help.
"If you're not going to [have lifeguards], next is to have monitors who may not be lifeguards but have training in water safety, first aid, CPR, drowning recognition," Osinski says. "Now maybe it's step down from lifeguards, but the water watcher is better than nobody."
Even someone without that kind of training—just a warm body to check on the situation and call for help when necessary—can work. Osinski suggests a person who makes regular visits at 10- to 15-minute increments. It won't save a life or prevent a drowning necessarily, but it can ensure a certain amount of oversight.
"Ultimately drownings and the changes in these kinds of things that occur in not-guarded pools are simply because nobody was there to enforce a rule, either a drinking rule or a horseplay rule or a child-with-parent rule," Ebro says. "In fact, the same person that hands out towels can be made responsible for simply sitting out there."
The statistics for drowning remain staggering. According to the National Safety Council, it was the fourth leading cause of unintentional death for people ages 1 to 77 in 2001 (second leading for ages 1 to 4, 6 to 18 and 20). That year saw 4,406 drownings, and for each of those, according to Dworkin's research, there were six to 10 near-drowning incidents that caused permanent neurological impairment. Markel's guide listed a statistic from The National Safe Kids Campaign that showed roughly 5,000 kids are hospitalized every year for drowning incidents. Their health-care costs are, of course, outrageous.
It's not really getting better, either. Dworkin has 29 concurrent drowning or near-drowning cases on his plate right now. What's worse than that? Many of them involve "very young kids" who were out of sight for less than five minutes. Drowning incidents remain more or less predictably constant, though Dworkin says drownings at public facilities have decreased. They have increased at private facilities like home pools. Overall, the numbers of incidents seem to rise with increasing aquatics usage.
"I think we have more participation," Ebro says. "We have made tremendous strides in providing protection, but because that's a proportional kind of increase, we continue to have proportional injury statistics."
Evans' company works with many summer camps and youth programs, and he's seen a rise in the percentage of children who are beginning swimmers or non-swimmers. That diversity of users, of course, increases risk because of their lack of experience. To address the drowning threat, many facilities have simply opted for shallow-water pools or zero-depth splash play areas, which have a significantly lower drowning risk.
In its aquatics risk-management guide, Markel Insurance listed three primary causes of drowning: unsafe conditions (broken equipment, cloudy water, obstructed views, etc.), unsafe acts (inadequate supervision, shallow-water diving, lack of rescue equipment, etc.) and errors in judgment (showing off, fatigue, distraction, etc.). Regardless of how ill-conceived a person's actions or behavior are, ultimate responsibility for the consequences falls on the facility's management.
Drownings themselves fall into two categories: active and passive. In the former, the victim is conscious as it happens and struggles against it. In the latter, people simply disappear—there's no struggle or cry for help. That can happen for a variety of reasons, from blackout to heart attack or a blow to the head. As Dworkin's swollen caseload shows, most drownings go unperceived, regardless of their active or passive nature.
"That surface struggle that most people would recognize as drowning is very brief," Osinski says. "But you still have a lot of time once that person submerges to rescue them before they're a fatality."
Although it sounds insensitive, drowning victims usually fall into two categories: floaters or sinkers. Children, because of they weigh less and have lighter bone structure, typically float when they drown. That's a general rule, but obviously it varies according to the child's age. Adults typically sink when they drown.
"We expect to find teenagers and adults on the bottom, and we expect to see children floating on the surface," Ebro says. "It depends on what your physiology is."
Simply because of their DNA, some people may have a genetic predisposition to drowning. Saving them typically requires more than lifeguard vigilance. Griffiths uses the example of a young woman from Chicago who died twice in water: once when she swam in a lake (emergency personnel revived her) and once in a pool (her parents revived her through CPR). Now she's not allowed to swim, and her mother carries an automated external defibrillator (AED) with her at all times.
"We've had a number of seizures and heart attacks in pools," Evans says. "For some reason, they may have had a heart attack on land, and it could have resulted in the same death, but the fact that it was in the water, for some reason, CPR does not seem to be as effective after a two-minute period."
Griffiths' research has examined two genetic drowning triggers: long QT syndrome and a "rogue" drowning gene called RyR2. Both reportedly predispose people to sudden cardiac arrest. Long QT syndrome is an abnormality in the heart's electrical system from defects in muscle cell structures. It predisposes people to a fast heart rhythm that can lead to sudden loss of consciousness and, eventually, death. Both RyR2 and long QT syndrome only can be detected by EKGs and DNA mapping, and the latter is not a cheap undertaking (roughly $5,000).
"Just because somebody dies in the pool…doesn't mean the lifeguard's at fault," Griffiths says. "Even with the quickest response and most efficient resuscitation efforts, a lot of these people would still die…so we have to anticipate these emergencies and be ready to resuscitate when we can."
Another problem, which isn't genetically based, is shallow-water blackout. That occurs when people hold their breath for too long and lose consciousness. What makes it more insidious is that it typically affects skilled athletic swimmers, the very people who are usually less of a concern to lifeguards. These athletic swimmers will often try to keep their breathing to a minimum for stroke efficiency, but that can easily lead to blackout. To combat that, Griffiths suggests establishing a clear rule that prohibits prolonged breath-holding to go along with a facility's other well-established rules.
One question that has haunted facility operators for a long time is why can't lifeguards see bodies at the bottom of a clear pool? Theoretically they should be able to see them, right?
Maybe not. Griffiths lowered mannequins into five different pools at Penn State and videotaped them from many different angles to find out. Before the pools opened, it was easy to spot the dummies at the bottom. What he discovered after the pool opened floored him.
"The little waves generated by swimmers in the pool—and I'm not talking about visual obstructions of swimmers on the surface blocking the view on the bottom," he says, "just surface rippling, surface agitation destroys the view of the victim on the bottom."
Even small ripples of water caused by breezes in outdoor pools were enough to completely erase the image of mannequin. Griffiths calls this "visual body blindness."
"The view of the victim on the bottom of the pool, under perfect conditions, crystal-clear water, very few people in the water, is distorted and even disappears with surface agitation," he says. "Just imagine how difficult it is for lifeguards to see victims on the bottom when the pool is crowded."
When that's the case, lifeguards are set up to fail in normal conditions, and all the training in the world won't help. The problem generally isn't discussed, even though it has a pretty simple solution: getting lifeguards in the water to check the bottom.
"Traditional lifeguard-training programs, the older ones in the country, have emphasized surface scanning," Griffiths says. "Once a person's on the bottom, they only have seconds to live, and the survival rate once they slip under the surface is significantly lower. I'm trying to encourage people to prioritize the bottom and sweep the bottom first."
Sometimes lifeguards don't understand what their eyes see. It's called perceptual body blindness, and it's a controversial subject. It basically states that lifeguards don't process the information their eyes see—like a body underwater—because they don't expect to see one there.
"Visually it is apparent to their eyes, but it's not included on the brain, and this happens all the time in all walks of life," Griffiths says. "Many water-safety traditionals don't want to believe it, but psychology studies that phenomenon all the time."
Osinski likens perceptual body blindness to security personnel at airports: They don't see the gun in someone's bag because it shouldn't be there. But she's not impressed by the idea.
"It's a reason—it's not an excuse," she says. "If your job is to be looking for people in trouble in a pool, you should see them…They're looking right at it, and they're trying to convince themselves that what they're seeing is a towel, not a person. That's why we try to train people, if you see anything out of the ordinary, you go."
Griffiths has a catchy way to say it: When in doubt, fish it out.
Over the past few years, a number of drowning-detection systems have come on the market. They range from simple underwater cameras to sophisticated computer systems that use underwater and above-ground cameras, complicated logarithms and motion detection to sound an alarm when someone appears to be in trouble. Not surprisingly, such systems cost a lot of money. Their manufacturers are quick to point out that these systems should complement lifeguards, not replace them.
They are becoming more common, though. Griffiths uses one such system, one of the more high-tech drowning-detection devices, in some of his pools at Penn State. Dworkin says the first such system was used in St. Cloud, Minn., at a high school where a kid drowned during gym class. The school district promptly installed three $75,000 systems in different pools, but Dworkin says the its enthusiasm was a little misguided.
"That's all well and good, but the reason why this kid wasn't found was because of cloudy water, not because they didn't have the assistance," he says. "The protection system doesn't work in cloudy water."
He also sees a potential problem with drowning victims who float, when these detection systems look underwater instead. Theoretically a lifeguard would see a floater, but it all reinforces the point that drowning-detection systems are complementary tools, not lifeguard replacements.
In general, the more layers of protection a facility has, the better. For example, consider outdoor pools, like those at a hotel/motel or apartment complex. They need to have isolation fencing around all sides of the pool. They need self-closing, self-latching and self-locking gates, which can only be opened using a key or swipe card. Gates need to open outward, away from the pool, because children have a tendency to push on gates rather than pull on them. Those kinds of protections can dramatically reduce the odds of an accident. Even if they cost money to implement, they're still cheaper than a settlement or litigation—and, of course, any human toll.
In an attempt to limit drowning potential, some facilities have opted for shallow-water pools. Some of these places have removed diving boards to prevent spinal injuries, so what's the point of keeping a pool deep?
"You don't need more than 6 feet of depth," Ebro says. "But if you have a shallower pool, a couple of things happen. One is it's much less expensive to operate from a mechanical standpoint—it's less water. The water column is less, so you can see. It's brighter on the bottom. In 12- or 16-foot pools, it's much harder, even in glareless conditions, to see someone on the bottom of a deep pool."
Some facilities have gone even more shallow, with 4-foot depths that allow children to stand up when they get in trouble. However, shallow pools like these actually can increase a different type of risk: spinal injuries from diving.
Generally speaking, the aquatics industry has made significant progress over the years in the prevention of shallow-water diving—but it still happens. Spinal injuries also occur in diving wells, where the diving area isn't big enough (victims strike the slope of the pool bottom instead of the deep water), and when horseplay causes someone to fall into shallow water. There are also spinal injuries that occur when people jumping in water land on someone. Obviously it's important to establish rules against diving, but they aren't enough by themselves.
"Just saying 'don't dive' is like saying 'don't spit on the carpet,'" Ebro says. "If you were told that your spit somehow chemically combining with the carpet causes an explosion, you'd probably not spit. But if nobody's looking, you'd probably spit. The same with diving: Some people feel there's really no consequence there."
Education plays a big role here, as well as the establishment of anti-diving rules and, more importantly, enforcing those rules. Places that have diving blocks should cover them or make them otherwise unusable when they're not in use. However, no matter how much facility operators warn people against diving in shallow water, no matter how big and obnoxious the signs prohibiting it are, some of the less intelligent swimmers will do it anyway.
"I think the signage and just having lifeguards attentive is about all you can do," Evans says. "And then having them prepared to respond because it's such a quick, unpredicted action."
Perhaps no other aquatic risk seems to get more publicity lately than entrapment. Drownings have more of an accidental perception and, in some cases, result from a victim's actions. Entrapment, though, seems more sinister. It's hard to blame a victim who died because her hair got caught in a suction grate. Because the incidents tend to be tragic or at least frightening, they get a lot of play in the media. What could be more horrifying than a child getting eviscerated in a hot tub?
Because of these types of occurrences, the aquatics industry has made great strides over the past few decades in entrapment prevention. Facilities can prevent entrapment accidents any number of ways, and for the most part, they have. It's at private locations where the worst accidents typically occur, like the boy in the hot tub. But Osinski says the accidents still are happening everywhere, and they're still the same types of accidents.
Suction entrapment comes in four varieties: hair, limb, body and mechanical. Each differs in both what it is and how it's prevented. But there are general solutions and guidelines facilities can implement to reduce the overall threat of entrapment.
For example, anti-vortex, tamper-resistant grates will work. Vacuum-release systems (a.k.a. SVRSs, safety vacuum release systems) make a big difference too, as they automatically shut off when there's a sudden increase in pressure, which would occur when a body part gets sucked up against a grate. Most pools have two drains now, not a single drain, which also helps. The drains need to be on different planes and a certain distance apart. Facilities need to have pump kill-switches located near the water.
Entrapment risk, of course, varies according to facility type. A splash play area won't have the same threats as a 25-year-old swimming pool. To assess the risk, managers need to take a comprehensive look at what they have at their facility.
Although they're sometimes treated as two different issues, water clarity and waterborne illness do overlap. Pathogens in the water can affect water clarity, and water clarity can reflect how much junk is in it.
"There's not a whole lot that are dying due to pool water chemistry," Griffiths says. "To me the biggest problem with poor water chemistry or pool operators is cloudy water. When you can't see the bottom, there's no excuse for that."
Suction entrapment may seem like it has the monopoly on horrifying stories, but cloudy water has more than a few of its own. Osinski cites a birthday party in Los Angeles where a little boy disappeared. The county spent $500,000 on manpower to search for the child, released an Amber alert and spent two days trying to find him. Turns out he was right there all the time—at the bottom of a pool whose water was too cloudy. He spent two days underwater.
"If you can't see the bottom of the pool, the main drain, the pool needs to be shut down, no ifs, ands or buts," Dworkin says. Considering the scope of the L.A. county tragedy, that rule sounds pretty reasonable. So does Griffiths' guiding principle: the more chlorine, the better.
"People are frightened of chlorine," he says. "I tell most people who come to me for swimming-pool operation, whatever you keep your chlorine at now, raise it 0.5 parts per million. To me, more is better, again from several different perspectives: a water-clarity issue, a water-safety issue and a water-quality issue that is killing all the bugs and germs in the pool."
Those bugs and germs have seemingly made more headlines these days, especially when it comes to cryptosporidium and E. coli. After an E. coli outbreak at an Atlanta waterpark in 1998, Six Flags mandated chlorine levels at all of its parks be kept between 3.2 and 3.5 ppm. Children in diapers also must wear special swim diapers.
"No matter how much we don't want to think of it, swimming pools are public bathing," Osinski says. "The only reason it doesn't look like your bathtub when you get out when you're grungy is we're doing something about this. We're adding chemicals, we're moving the water, we're filtering the water."
The threat comes from pathogenic organisms (E. coli, cryptosporidium) and organic contaminants (waste). A formed-stool accident requires a little less vigilance than one that involves diarrhea, but both need to be treated seriously by trained pool operators. The easiest way to avoid all of this is to have trained pool operators, but that's a bigger challenge than it should be.
"The majority of pool operators out there who are not trained don't have the skill to do that," Osinski says. "They don't know how to maintain 20 parts of chlorine for eight hours and how to take the appropriate readings."
Splash play areas are at a particular risk for pathogens (as well as slipping, tripping and eye injuries) because some manufacturers often sell them to facilities by saying they don't require supervision. That's not true. Last summer, Osinski says there were three major outbreaks of waterborne illnesses in her area, and that directly comes from a lack of water-chemistry vigilance. She also thinks the number of outbreaks hasn't really changed—just knowledge of what they are. Dworkin agrees.
"In the past where we've seen people that we think may have been as an example hepatitis, it turns out to be cryptosporidium or something," he says. "The testing has improved, the awareness of the hospitals has improved, so the diagnosis has improved."
Although it has become less prevalent, electrocution is still a threat. Griffiths sees them every year, but Evans has never had one in the programs he insures. The threat can come from underwater lighting fixtures to lightning, and the ways to address it obviously differ.
As a general safety precaution, Griffiths recommends facilities have their bonding and fixtures inspected by a licensed electrician every five years. Bonding is when all the metal parts of a facility are connected to a common copper wire buried in the ground and connected to a reinforced steel structure. It reduces the voltage gradient around the facility and helps reduce the effects of lightning.
Speaking of lightning, Dworkin suggests pool evacuation at the first indication of it—even indoors. Several states—North Dakota, South Dakota, Maryland, Rhode Island and Michigan—recommend indoor-pool evacuation at the first indication of lightning. Delaware has a law mandating it. Griffiths describes such precautions as "asinine."
"I believe that, if your pool is grounded and you're indoors," he says, "and you passed your electrical inspection, and it's done on a regular basis, that it's literally safer for people to be swimming in an indoor pool during a lightning storm than closing the pool and having those swimmers under shower heads, on toilets, on telephones, in front of computers or having their parents drive in a storm to pick them up."
Could there be more to keep in mind when running an aquatics facility? Probably. As everything becomes more specialized, and the industry learns more, the list of risk will probably grow. But it's not impossible to address those risks; it just takes vigilance. For Evans, it comes down to hiring staff who knows what they're doing and investing in their training. A knowledgeable, alert team automatically will reduce the risk considerably. Training them is key.
"First and foremost, it's absolutely critical that a facility manager needs to establish in writing appropriate standard operating procedures for personnel and emergency-response plans," Dworkin says. "Their personnel need to be drilled in those protocols so that, when it hits the fan, they know automatically how to respond."
While it's a good idea to look at how risk has been addressed historically, Griffiths warns against relying too much on the past for guidance. Take entrapment as an example: What worked 20 years ago is probably dangerous negligence now.
"They can't just do it the old-fashioned way," he says. "They have more resources so they have to look at more references. If they want to base their risk-management procedures on what's readily available through those national training organizations, they're not going to be doing their jobs. They're going to be doing what the majority of people are doing, but that's not enough."
Dworkin always stresses a couple of different axioms with the people he encounters. Murphy's Law figures prominently.
"Anything that can happen will happen, and when it happens, it happens at the least opportune time," he says. "And Mother Nature's a bitch."
He also stresses the rule of numbers: The more people who use a facility increase the likelihood of a significant accident.
"Every day that goes by that you don't have a significant incident brings you one day closer to when it's going to happen," he says. "As a result, facility managers and operators and lifeguards need to be prepared so that when it does happen, they're ready for it."
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