Choi, Seongeun; Park, Sang Won
Deceased
Seongeun Choi and Sang Won Park
Demographics
unknown
Coroner
Priestly
Date of death
2009-02-14
Finding date
2011-11-24
Cause of death
Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident; Mr Park: drowning/immersion due to rafting accident against background of multiple injuries
AI-generated summary
Two language students died following a white water rafting incident on the Tully River. A collision between rafts diverted one raft into a hazardous channel, causing it to strike Sieve Rock and flip. Both occupants became entrapped underwater. Ms Choi was rescued and received CPR but died from hypoxic brain damage five days later. Mr Park remained entrapped and died from drowning with crush injuries. The coroner found that RnR Adventures' risk controls for raft collisions were weak, relying on undefined 'river etiquette' rather than documented procedures. Guides had different understandings of traffic management at the rapid. The coroner recommended formal rapid-by-rapid risk assessments identifying collision hazards and specific control measures, with external expertise to strengthen RnR's safety management systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- collision between rafts near entry to 2-15 rapids
- diversion of raft onto hazardous route (chute 4 toward Sieve Rock)
- raft striking Sieve Rock and flipping
- entrapment underwater beneath rock with prolonged immersion
- weak risk controls for raft collision management
- reliance on undefined 'river etiquette' rather than documented procedures
- lack of traffic direction at rapid entry
- different guide understandings of entry protocols
- no rapid-specific risk assessments or documented procedures for 2-15 rapid
- crush injuries from rock displacement (Mr Park)
Coroner's recommendations
- RnR review its operational procedures by conducting formal risk assessments of each set of rapids, identifying all hazards, selecting control measures appropriate to the unique attributes of each set of rapids that mitigates the risk to a defined acceptable level, and then periodically reviewing the control measures for their effectiveness
- The hazards, risks and workings of the control measures should be shown as an overlay on current maps of the rapids with explanatory notes about relevant strategies, and safety critical strategies should be highlighted
- Documented procedures should be incorporated into training and auditing programs
- In implementing formal risk assessment of each set of rapids, RnR include the prospect of collision between rafts and with rocks as a potential initiator of a flip as a hazard, assess the risk of such an event, and select control measures that will mitigate that risk to a defined acceptable level
- RnR obtain external assistance with the risk management process
- Other white water rafting operators should consider these findings and recommendations in implementing similar recommendations arising from previous inquests
Full text
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