Robinson, Ian
Deceased
Ian Robinson
Demographics
47y, male
Date of death
2007-07-31
Finding date
2011-11-03
Cause of death
drowning
AI-generated summary
Ian Robinson, a 47-year-old experienced swimmer and teacher, died by drowning during a commercial whitewater rafting trip on the Tully River in Queensland. The raft capsized at Wet n Moisty rapids after contact with rocks, and Robinson became entrapped underwater between rocks. Despite rapid response by guides who located and extricated him within minutes and initiated CPR, he could not be resuscitated. The coroner found the guide was appropriately qualified, the raft and safety equipment adequate, and the rescue response exemplary. However, the coroner identified a systemic gap: RnR Adventures lacked formal documented risk assessments for specific rapids, relying instead on individual guide experience. The coroner recommended implementing structured risk management processes including hazard mapping, documented safe routing procedures, and competency assessments tailored to each rapid's specific hazards, particularly for high-risk rapids like Wet n Moisty where entrapment points exist and cover positions are limited.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- raft capsize after contact with rocks at Wet n Moisty rapids
- foot entrapment between rocks underwater
- prolonged immersion
- lack of documented formal risk assessment for rapids
- limited cover positions available due to terrain constraints
- absence of documented procedures for safest manner of rafting specific rapids
Coroner's recommendations
- RnR Adventures should review its operational procedures by conducting formal risk assessments of each set of rapids
- Identify all hazards including potential sieves and entrapment dangers at each rapid
- Select and document control measures appropriate to the unique attributes of each rapid that mitigate risk to a defined acceptable level
- Periodically review control measures for effectiveness
- Create maps showing hazards, risks, control measures, preferred paths through rapids, locations of known entrapment points, and cover positions with accompanying explanatory notes
- Highlight safety-critical strategies in documentation
- Incorporate documented procedures into training and auditing programs
- Implement formal competency assessment processes for guides with particular focus on rapids requiring higher technical proficiency
- Establish internal investigation processes for flip-overs as 'non-conformities' to extract lessons and facilitate periodic review of procedures
- Implement periodic auditing based on documented standards
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