OFFICE OF FINANCIAL MANAGEMENT LOSS PREVENTION REVIEW TEAM DROWNING PREVENTION WASHINGTON STATE PARKS AND RECREATION COMMISSION REPORT TO THE DIRECTOR OF THE OFFICE OF FINANCIAL MANAGEMENT NOVEMBER 2005 TABLE OF CONTENTS Section 1 - Executive Summary ................................................................................... 1 Drowning as an Issue for State Parks .......................................................................... 1 What Drowning Costs................................................................................................... 2 Summary of Recommendations ................................................................................... 4 Team Members ............................................................................................................ 5 Section 2 - Introduction ................................................................................................ 6 The Program ................................................................................................................ 6 This Review.................................................................................................................. 6 Methodology................................................................................................................. 6 Scope Of The Problem................................................................................................. 7 Section 3 – Risk Assessment of the Incidents Triggering Review ........................... 8 Summary Description of Incidents................................................................................ 8 Steamboat Rock State Park, July 12, 2003...........................................................................................8 Paradise Point State Park, August 24, 2003 .........................................................................................9 Riverside State Park, September 3, 2003 ...........................................................................................10 Alta Lake State Park, September 20, 2003 .........................................................................................11 Nolte State Park, July 11, 2003 ...........................................................................................................12 Role of Rangers ......................................................................................................... 12 Causative Factors ...................................................................................................... 13 Section 4 – Practices to Prevent Drowning .............................................................. 14 Agency Culture........................................................................................................... 14 Managing Environmental Factors............................................................................... 16 Beach and Waterway Assessment ......................................................................................................16 Department of Health’s Role................................................................................................................17 Parks Current Beach Assessment Tools.............................................................................................19 Environmental Limits on Swim Beach Development or Repair ...........................................................20 Data Assessment to Prioritize Loss Prevention Work .........................................................................20 Beach Closure .....................................................................................................................................21 Signage ...................................................................................................................... 21 Liability Risk of Posting Warnings........................................................................................................22 Universal Signage................................................................................................................................23 Boat Launch Signage...........................................................................................................................24 Swim Beach Signage...........................................................................................................................24 River Waterways..................................................................................................................................25 Managing Behaviors................................................................................................... 25 Lifeguards ............................................................................................................................................25 Personnel Training...............................................................................................................................30 Public Education and Outreach ...........................................................................................................31 Drowning Prevention Collaboration .....................................................................................................31 Use of Flotation Devices......................................................................................................................33 Boating Safety Program.......................................................................................................................35 Coordination with Other Agencies .......................................................................................................36 Drowning Prevention LPRT Report Page i November 2005 Section 5 – Risk Management at State Parks ........................................................... 37 The Agency Definition of Risk .................................................................................... 37 Historic Efforts to Manage Risk .................................................................................. 38 Utilization of the Report .............................................................................................. 40 Current Risk Management ......................................................................................... 40 Culture of Safety ........................................................................................................ 41 Data Collection........................................................................................................... 42 Risk Management is Local ......................................................................................... 44 Conclusions about Risk Management at Parks.......................................................... 44 Section 6 - Recommendations ................................................................................... 45 Beach Assessment..................................................................................................... 45 Personal Flotation Devices......................................................................................... 46 Signage ...................................................................................................................... 46 Data Collection and Analysis...................................................................................... 47 Train Rangers, Regional and Headquarters............................................................... 48 Develop Risk Management Processes within the Agency.......................................... 48 Lifeguards – Targeted Reinstatement of the Program............................................... 49 Interagency Involvement ............................................................................................ 49 Legislation and Legal Advice...................................................................................... 50 Other Observations .................................................................................................... 50 Section 7 - Conclusion................................................................................................ 51 APPENDICES Appendix A: State Parks and Recreation Commission Background Information Appendix B: Report to LPRT – Literature Review on Effectiveness of Signage Appendix C: Public Entity Drowning Prevention: Best Practices Analysis Appendix D: State Injury Profile for Washington Appendix E: LPRT Document Log Page ii Drowning Prevention LPRT Report November 2005 To the Director of the Office of Financial Management: Pursuant to RCW 43.41.370 and .380, we have concluded our review of the assigned incidents reported by the Washington State Parks and Recreation Commission to the Office of Financial Management. Our Loss Prevention Review Team report follows, and contains our analysis of the root causes of the incidents, and recommendations to mitigate and prevent future similar occurrences. We hope the recommendations are useful to the Washington State Parks and Recreation Commission, and that action will be taken to help prevent drowning in state parks. Sincerely, The Loss Prevention Review Team Anthony Gomez Gus Gustafson Suzanne Mayr Dr. Linda Quan Tom Warren Drowning Prevention LPRT Report Page iii November 2005 Section 1 EXECUTIVE SUMMARY Drowning as Washington State’s parks are a treasure. The agency operating an Issue for the parks, the Washington State Parks and Recreation Commission (State Parks) faces many challenges: maintaining State Parks the parks in a myriad of settings,