Long Term risk Management

This document gives my recommendations for risk management for those paddling sea kayaks into challenging conditions.  These recommendations mainly applies to trips to exposed and committed locations where difficult conditions of wind, swell, currents, or distance, may be encountered.  Further, these recommendations are meant to manage some risks that accrue over time and multiple trips.  It has taken me some time and experience to understand these time accrued risks.  The need for my recommendations are best understood relative to these risks.  Therefore, a significant section of this document is dedicated to describing the problem of going out into challenging conditions again and again.

These are my personal conclusions and recommendations that I decided to use in my trip planning.

Tom Unger, May 2024

Problem Definition

How do we lead trips over a decades long career in a way that minimizes the possibility of incidents?  Similarly:  how does the sea kayaking committee offer a program of outings in a way that minimizes the possibility of incidents?

First, some definitions.  

• An “incident” is some form of harm, physical or psychological, to people or to equipment. 
• “Risk” is the potential for harm.  All risk has two attributes:  a probability of occurring and severity of the harm.  
• “Risk assessment” is to identify the potential harms, their severity, and probability.
• “Risk management” are actions that reduce the probability of a harm or the severity of that harm.
• “Safety” is about keeping potential for harm below a threshold we are comfortable with.  No activity is completely safe, but some are safer than others.
• “Risk tolerance” is our own willingness to assume a risk for the perceived reward.  Reward perceived is highly individual and therefore risk tolerance is highly individual.

There is one intuitive solution to long term risk management, which does not work and creates adverse incentives:  Leaders must take care to exercise good judgement and prevent incidents.  Leaders should take care and should exercise good judgement, but this prescription alone won’t actually prevent incidents.  Incidents come from a sequence of events.  Some are common patterns which we can learn to recognize while others arise in unexpected ways.  As an example, there was a trip where the leader took the group up a creek where they stopped for lunch.  During lunch, the tide fell. When they paddled back to the sea, the current was faster with some tricky bends.  It is difficult to anticipate events like that.  Over the course of a long career, we will eventually encounter a combination of events that lead to difficulties we did not foresee.  Further, statistical variation (randomness) tells us that there will be times when actual conditions vary widely from what was forecast or what was observed at launch.  Over the course of a long career, there will be outings where conditions are much more difficult than we anticipated.  Over time, we can’t anticipate all ways incidents may happen.

Secondly, the human mind is not good at constant vigilance.  If you have every tried to meditate on one object, you certainly have experienced this.  You sent your mind on the object with the intent to hold it here.  Sometime later, often as quickly as a few breaths, you recognize that your mind has wondered.  The instruction to “set a firm intention to stay on the object” does not work.  Similarly, the instruction to “take care to exercise good judgement at all times” does not work.  Within our minds there are competing motivation.  Good judgement and prevention of harm is one.  Having particular, rewarding experiences is another.  Offering opportunity to others is another.  Glory and reputation may be present.  Desire to fit a schedule or fufull commitments is common. Sometimes these are in ascendence and override good judgement.  

Further, two process cognition theory tells us that we prefer to rely on a process that provides quick answers using pattern matching and heuristics.  

A bat and a ball together cost $1.10.  The bat costs $1.00 more than the ball.  How much does the ball cost?

This is a classic question meant to elicit the wrong answer from our fast cognition.  $0.10 feels correct, but it is wrong.  To get the right answer, you have to do the math.  You have to engage your slow cognition.  This takes deliberate effort and we are not likely to do this unless prompted.  We are reluctant to fire up slow cognition because our fast cognition is often correct and takes less effort.  “No reason to go to all that work when I have the correct answer here.”  Even when it is the wrong answer, it will feel like the correct answer.  If wrong answers always felt wrong, we would never make mistakes.  We have a set of heuristics (fast thinking) that can give us wrong answers.  

Our patterns of faulty cognition have been studied and named.  It is good to learn about them.  However, learning about them does not prevent us from using them.  More importantly, learning about faulty cognition not protect us from accepting wrong answers from our fast cognition.  

So, there are two things that make occurrence of incidents over time likely:  conditions will surprise us and we will make mistakes in our risk assessment.  Expecting leaders to prevent incidents or near misses through constant alertness will fail.

Expecting infallibility creates an adverse incentive.  When an incident or near miss happens, the implication is that the leader got something wrong.  They failed to be diligent in some way.  We are adverse to being wrong.  We are adverse to being seen as incompetent by our peers.  The natural response is to hide the near miss or incident.  It didn’t happen, I didn’t do anything wrong.  We loose the ability to hold candid debriefs and learn from events.  

There is a related adverse incentive.  We often read incident reports with an eye to discover what the people did wrong.  Having discovered that, we can then take care to not make that mistake ourselves a thus be safe in our pursuits.  We are motivated to assign blame to leaders.  In reality, we are subject to the same causes of incidents:  unexpired sequence of events and mistakes in our risk assessment.

This is not to say that we should not take care to use good judgement, make accurate assessment of conditions, engage in thoughtful analysis of risks, and endeavor to learn from that analysis.  We should definitely do that.  Failure to take care in these areas will increase the chance of harm.  We can become better at risk management but we can not become infallible.   

What will actually reduce the risk of incident through a decades long career of doing trips?  Primarily, having sufficient buffer.  “buffer” is a concept in risk management that means having extra such that when problems occur, there is buffer between the problem and an incident.  Buffer takes many forms, such as excess skill, excess strength and endurance, excess gear, excess time and so on.  

When we paddle in calm conditions we often have excess skill and strength.  When our trips are well within our fitness level we have excess endurance.  When we paddle along the accessible and populated shores of Puget Sound we have buffer in the form of options to get out of the environment and seek land based services.  However, when we take on more challenging trips we often don’t have those buffers.  When we paddled in remote places, we don’t have the buffer of land based services.  When the shore is not accessible due to it’s shape or due to breaking waves, we don’t have the buffer of escape from conditions.  When the winds are strong, we may not be able to get to protected waters.  We are in a more committed environment and must endure the conditions until we can exit the conditions.  If we are paddling near the group’s capacity and conditions get a little harder, we are beyond capacity, and there may be some harm.  

As leaders, we want to calculate the groups capability and the conditions to decide:  does this group have sufficient capability for these conditions.  Like any calculation, we won’t always get this right.  Over the course of many trips, some trip participants will not be as capable as expected.  Some conditions will be harder than expected.  If every trip is its own unique evaluation of the group and conditions, eventually we will find ourselves out on a mis-calculated trip with insufficient buffer for safety.

There are two solutions to this.  First it to develop some rules for this capacity calculation that should provide us with sufficient buffer.  When we develop rules ahead of time, we do so with more thought, putting more effort into them.  We are not subject to any competing pressure of a particular trip.  Thought out ahead of time, we are more likely to come up with good rules.

Our second method for ensuring sufficient buffer, and better risk management in general, is to engage other people in risk management.  The more minds, the less likely that important considerations will be overlooked.  The more likely that careful reasoning will be engaged.

Of course, every trip is different, and for any given trip there may be some good reason for deviating from the rules.  But, when we start to deviate, we are again making trip specific calculations and are subject to the meta risk of getting our calculations wrong.  We should only deviate from the recommendations when we good reason to deviate.  What is a good reason?  It is well though out.  To help ensure we think things out, we can engage accountability.  When we expect that our decision will be evaluated by someone else - we will be held accountable - we are more likely to engage our slow thinking and do a thorough evaluation.  We are more likely to have good reasons for our decision.  Two risk management techniques help us engage accountability.  

In “not writing the report” we imagine there is an incident and a report is written.  We imagine how that report will read, the description of actions we took.  We imagine our peers and experts reading the report.  We want it to read well.  We want the actions we took to good, reasoned actions.  “Not writing the report” encourages us to identify the actions that are not so well thought out and change them.  

In “addressing the jury” we imagine there has been an incident, we are not at trial, we are then called on to explain a particular decision.  “Sir, please explain why you thought it reasonable to take this group of paddlers to that exploded coast line?”  Again, we are imagining being accountable for our decision.  If we have reasons for the decision that we would be comfortable articulating in such a confrontational situation, they are probably good reasons.  If we are not comfortable, we will be encouraged to make a different decision.

It is good practice to get a second opinion on deviating from the recommendations.  In anticipating asking someone else, we are engaging accountability.  In asking someone else, we are getting another mind looking at the situation.

But we should be cautious of deviation from our own rules for special circumstances.  The more commonly we do this, the less special each instance is and we are back to apply judgement every trip, which is prone to failure.  

Problem Solution

The solution to managing risk over a long career is to develop some rules for yourself. Start by assessing your own ability, what you can paddle in and what you can help other people in

• max wind that you can maneuver your boat in
• max ocean swell, particularly how it interacts with wind waves and the shore
• max surf
• max current turbulence.

Then consider what conditions leave you enough capacity to help other paddlers.  How much buffer do you want and in what form? 

Example Rules

These are roughly my rules for planning trips over the long term, particularly when I may choose to go into rough conditions of winds above 20kt, ocean swell above 8 ft, and in remote locations. 

Clearly State Maximum Expected Conditions

For any trip, and especially with SK V trips, leaders should include a clear statement within the Leader Notes Section of the maximum expected conditions, where applicable:  wind speed, wave height, current speed, swell or surf height, fog, rain, etc.  

“Max wind speed” is subject to different interpretation.  Your meaning should be defined in the Leader Notes.  Examples of this could include descriptions such as “sustained winds of up to 15 kts”, “wind gusts of up to 15 kts” or “average wind speeds up to 15 kts.”

This serves two purposes.  It provides information for participants to self-select.   It provides clear criteria for leaders to make a go, no-go decision.  This reduces the possibility of mission creep where in more difficult conditions are accepted due to vague specification and momentum.

This does not mean that maximum expected conditions shall never be exceeded on a trip.  One may choose to launch with a forecast at maximum conditions and then encounter conditions that exceed the maximum.  

On a multi-day trip, the ability to control for maximum expected conditions is reduced.  Leaders should consider extra buffers such as:  stronger group, more time, or no-go at forecast conditions at 80% of maximum conditions.

Party Size and Composition

Size

Small parties have fewer resources and fewer options to deal with incidents.  Large parties are more difficult to manage.  It is harder to get people together,  It is harder to communicate to everyone.  Between “too small” and “too large” there is a happy party size.  But this exact number depends on what conditions your are going into and the party composition. 

Size Guidance

• 3 paddlers:  this is the minimum size.  Rescue options are reasonable, but not great.
• 4 paddlers:  Rescue options get better.  Two can tow a disabled paddler and assistant.  One can stay with the disabled paddler while 2 go for help.  4 competent paddlers is adequate.
• 6 paddlers:  When strong wind is my main concern, this is the maximum party size I’m comfortable with.  In wind, everyone is challenged to handle their boat.  Strong wind makes it difficult to come together and to stay together.  It is difficult to communicate.  Anyone who needs assistance, needs constant assistance.  There is no place you can park someone that is safe.  However, rescue options with 6 are significantly better.  Disabled paddlers can be towed by 3 with 1 to roam and rotate into the tow.  The group can be divided into 2 tow teams of 3 each.  
• 8 paddlers:  when strong winds are not the primary concern, safe stopping places are more common.  It is easier to come together and communicate.  Challenged paddlers can be put in a safe environment and cared for individually.
• Larger groups:  I become uncomfortable managing such groups in conditions.  Communication is difficult, separation more likely.  I must build in other forms of buffer, such as escape to safe landing, easy conditions, or very capable co-leaders, able to operate independently of me.

Composition

Overall party capacity for paddling in conditions depends on the composition:  the skill level of individuals.  We do want to take inexperienced paddlers in to rougher conditions to build their capacity and provide rewarding experience.  To do so, we must have sufficient experienced paddlers to care for them.  A strong paddler may have extra capacity to care for 4 other novice paddlers in calm conditions, 2 others in 10kt winds, 1 other in 20kt winds, and no others in 30kt winds, their personal maximum.  So consider the extra capacity within the group for the expected conditions.  We can roughly categorize paddler’s ability and excess capacity as:

• Condition Novice - someone with training but little experience in the conditions. Can probably, but not certainly, manage their own boat.  Their ability to assist others is limited.  They are learning personal judgment and have no basis for judging group ability.
• Condition Competent - someone with experience paddling in the conditions. Can manage their own boat, make personal judgment decisions, and assist others when directed.  May not be able to slow their own paddling to stay together or notice paddlers who need help.  Limited capacity to judge the group's ability
• Condition Leader - Someone with significant experience paddling in the conditions.  Can manage their own boat, assist others in need, make group level plans, and make group level judgment decisions.  Is able to adjust their paddling to stay with less experienced paddlers.

Composition Guidance: 

• 1 condition competent or leader paddler for every novice.  1 to 1.  Each novice may need personal care.
• 1 condition leader for 3 others.  1:3.  When there is only 1 person with capacity to hold the large picture and assess group performance and risk, 3 people may be all they should be watching over.
• 2 condition leaders on all committed trips generally advised.  Two people with capacity to hold the large picture improves safety.

Composition Evaluation:

We can evaluate the party composition using

• +1 for every condition leader
• 0 for every condition competent
• -1 for every condition novice

We want to build teams with a score >= 0.  We may decided that some larger number, more capacity, is needed for a particular trip.

At pre-launch, we should assess the group’s capacity.  People’s capacity changes over time.  People’s assessment when viewing the actual conditions may be different than a theoretical assessment done in the comfort of their living room.  At pre-launch we can ask participants to self-evaluate and show that with: 

• Thumb-up “I’m a condition leader today”
• Thumb-sideways: “I’m condition competent today”
• Thumb-down:  “I’m condition novice today”

If there is any concern about social influence, this can be done such that only the leader(s) see individual assessment.  However, I think it good for everyone to be aware of other member’s capacity on any given trip. 

There are many other factors that may apply to party size and composition, such as ability to get to protected waters vs commitment of the route.  Committed trips may require higher skills.  Lower max conditions will allow larger groups.  Training, done in a selected venue with exits to safer water, allows larger groups and lower skill.  

Paddle Together

Paddling together makes it easier to assist each other, to join up for planning, and to communicate when joined up.  Inability to paddle together indicates the group is in conditions that are too difficult for them as a group.  If the group cannot paddle together, the mission should be scaled back.  

The formation I like for paddling together is to have everyone in a lateral line, such that all party members are easily seen.  Gaps between paddlers should be somewhere between half a boat length up to a distance you can shout across and paddle across in under 30 seconds.  If anyone falls behind, the whole group slows.  Pace is that of the slowest paddler.  

I don’t use this formation all the time.  In calmer conditions where people are not likely to get into trouble we are more relaxed, which allows people freedom to explore.  However, if you never practice paddling together, it is likely you will not be able to when conditions get rough. 

Many of our groups are newly formed, how do we know they can paddle together? By intentionally doing so in the conditions, for 10 minutes or longer.  Early in every paddle, ideally in expected conditions, have the group paddle together for a significant distance. After starting, identify a point ahead on the route by 10 or 20 minutes.  Far enough that people will have time to experience the conditions.  Not so far that turning back is difficult.  Far enough that the leader is able to observe the group’s ability to consistently paddle together. Then give the instruction to paddle together, to that point.  

On arrival at the point, take time to assess conditions and the group’s ability to paddle together.  If the group is unable to paddle together when fresh and there things are going well, will they be able to when tired and there are problems and stress?  Confirm or change the mission.

Intentional Separation

A corollary to paddling together is to only separate intentionally with:

• Each party has the resources needed for their mission
• A plan to meet up
• Communication system identified and tested

Enlist Everyone In Risk Management

We are all subject to the meta risk that we will make errors in our risk management and judgment.  The protection against this is to engage all participants in risk management.  This is great in theory.  In practice, the halo effect is real, causing deference to the leader and less experienced paddlers do have less developed judgment.  Still, leaders want to hear from everyone.  The leader may have more experience, but each individual knows how they are feeling better than anyone else.  To engage participants, leaders must lean into this. Suggestions for this include:

• Ask for engagement
• Follow up by listening to and accepting feedback.
• Ensure the party has members who are capable of risk management. 
• Eliminate obstacles to communication:
• A party size small enough that everyone can hear and be heard
• Discussion held at places that 
• stop a feeling of forward momentum toward the obvious action and 
• people can come together for easy communicaiton
• people are not distracted
• Ask and leave silence for people to speak up.
• Consider ‘secret’ voting to avoid peer pressure

Debrief

All paddlers are developing judgment and will make errors.  We learn through review.  Therefore, take time to debrief within the group:

• Debrief trips back on shore or daily on multi-day trips 
• Debrief significant incidents, such as near misses, at the next opportunity for unhurried discussion.