Moore v. North America Sports, Inc. and USA Triathlon
Date: March 22, 2009
35-year-old Bernard Rice was an athlete competitor during the November 04, 2006 Ford Ironman Florida event held in/at Panama City Beach, Florida. There were approximately 2,000 – 2,500 participants in the swim portion of this competition.
During the second lap of a 2-lap 1.2-mile course, other athletes began waving for help to get the attention of the designated on-water spotters, lifeguards, and rescue personnel. Two rescue divers (John Mills and Kerry Dutton) entered the water and approached Mr. Rice. Once they reached him, they assessed him to be unresponsive and in respiratory and cardiac arrest. Mr. Mills initiated rescue breaths while in the water, while Mr. Dutton attempted to maintain an airway by keeping Mr. Rice’s head out of the water.
A Personal Watercraft (PWC) with an attached rescue sled arrived at the scene during which time Mr. Rice was placed on the sled for transport to the shore. Once Mr. Rice was on the board, the PWC transported Mr. Rice with Mr. Dutton securing Mr. Rice to the sled, while Mr. Mills performed chest compressions.
Upon arrival to the shore, rescue breathing was initiated by Dr. Cathy Velazco, M.D., an anesthesiologist and wife of one of the competitors, while someone else performed chest compressions. EMS personnel arrived on the scene as resuscitation efforts were continued. Dr. Velazco intubated Mr. Rice and he was then loaded onto a vehicle for transport to the ambulance located on the Boardwalk.
Resuscitation efforts were continued in the ambulance and enroute to Bay Medical Hospital. Epinephrine and Atropine were administered by EMS personnel. Enroute to the hospital, the EMS personnel were able to obtain a pulse prior to arrival at the hospital.
Upon arrival at the hospital, Mr. Rice presented with a strong femoral pulse, but with no spontaneous respiratory effort, and with no spontaneous neurological activity.
Mr. Rice had no prior history of any significant or contributing medical problems. Barney Rice expired on November 7, 2006.
It is reported the temperature was approximately 46 degrees at the start of the race. Numerous comments had been posted on a blog after this event including,
“I did IMFL this year as well and could not believe the direction and the magnitude of the swells this year….What I found frustrating was the lack of boats and jet skis on the course.”
“That was an ugly, ugly swim….It was like a mosh pit out there between the swells and the other triathletes.”
“The waves were really big: I’d say 4 – 5 feet or more, plus a lot of chop on top of that….The race announcer had said before the race that the seas were calm (a lie!).” Posted by Robin Wangberg.
“The swells and chop out there are pretty intimidating, and I really feel for the people who are not strong swimmers.”
“The second loop seems much harder than the first, and it seems as if the wind has picked up….The first large orange buoy has blown over onto its side, and we have to swim under it to make the turn. After the turn I was heading directly into the wind, and the chop is heavier.” Written by Paul Carmona.
“The more than 2,200 competitors entered the Gulf of Mexico this morning facing cool air temperatures and a relatively difficult swim thanks to the choppy water and strong current that took many competitors off course.”
The Report of Autopsy listed cause of death as drowning, and the manner of death as accidental. The autopsy findings showed moderate pulmonary edema with moderate cerebral swelling with herniation.
Timeline:
05:00 Athletes begin arriving at the transition zone at the Boardwalk Beach Resort
07:00 Race started
08:24 EMS Call Received
08:25 EMS Dispatched
08:26 EMS En-route
08:25 EMS Arrived
08:38 EMS Arrived
08:30 Asystole Confirmed by EMS
08:45 Epi Administered
08:47 Atropine Administered
08:48 Epi Administered
08:52 Atropine Administered
08:52 EMS Departs
09:04 Arrival at Hospital
Note: These times were taken from the EMS Incident Report. The times may not be accurate as it shows EMS dispatched at 08:25 hrs. and an arrival time of 08:25 hrs. There is no patient contact time provided. Reports from several witnesses indicate it was approximately 5 minutes before EMS arrived on scene from the time the patient was transported to shore with CPR in progress.
Aid Stations were established on the Bike Course (approximately every 10 miles with a Special Needs station at mile 56). Aid Stations were established on the Run Course (approximately every mile, with a Special Needs at mile 13).
There was no ambulance stationed on the beach, nor was there a medical tent provided. When the water rescue team transported Mr. Rice to the shore, no medical personnel were on shore waiting to receive him and take over resuscitative efforts. Basic Life Support care was continued by bystanders or BLS personnel while waiting for ALS intervention which arrived on scene approximately 5 minutes later.
USAT SANCTIONING APPLICATION
The USAT Sanctioning Application contains a section identified as Swim Course Safety Plan that identifies Tim Johnson as the swim course coordinator. This Swim Course Safety Plan indicates there will be a mass start with approximately 2,250 athletes, and includes the following additional information:
Lifeguards
This Plan also indicates that 1 lifeguard is required for every 50 swimmers and that a total of 44 lifeguards would be required.
Watercraft
The Plan indicates there will be watercraft “operating the swim course”. Furthermore, it indicates there will be 35 watercraft operating the course.
Medical Safety Plan
The application also contains a Medical Safety Plan that indicates a staff of 100 on the medical team, of which 10 will be at the race finish line. The application also states there will be 6 ambulances dedicated to the event and 6 ambulances on call. It also identifies Marc Lees as the Safety Director. This Plan also includes a list of Emergency Services that include the following:
• Bay County Sheriff’s Department
• Panama City Police Department
• Gulf Coast Medical
• Bay County EMS
However, even with these resources, the Police Department wasn’t notified of this incident until at least two hours after the incident. There were no ambulances at the swim event, and, as evidenced by the fact it took approximately 5 minutes for EMS personnel to respond to the scene after Mr. Rice was brought to shore is indicative of the fact there were no EMS personnel stationed at the swim event. It is also indicative of the lack of communications in place during this event.
2006 ATHLETE INFORMATION GUIDE
All competitors supposedly were issued a 2006 Athlete Information Guide. The following paragraphs are contained within this guide:
“On race day, you will see an Ironcrew of nearly 4,000 volunteers ensuring you a safe and pleasant trip to the finish line.”
“The safety of each swimmer is our prime concern….Visual aid will be provided by the lifeguards, divers, canoes and kayaks, buoys, and aquatic crafts that line the course.”
This guide contains a section, Medical Information, that talks about temperature problems. However, this information was written for Madison in July – not Florida in November.
There is no additional information in the manual of any significance regarding the swim event. However, it does mention the dangers of hypothermia, although it refers to the temperatures in Madison, with no mention of the hazards, risks or dangers associated with this event in the ocean in Florida.
2006 FORD IRONMAN STAFF GUIDE
The Guide describes several Plans, including the Garbage Plan, Security Plan, Vehicle Plan, and Ice Plan. It makes numerous references to a Boat Plan, but the Guide does not contain a written Boat Plan, nor does it contain any Emergency Action Plans (EAPs) or Emergency Response Plans (ERPs).
The Staff Guide identifies Tim Johnson and RR as the Set-Up Team #5 for the Swim Event and it identifies Johnson as the IMNA Contact, and Russell as the Swim Captain. The Guide identifies staffing and equipment resources necessary for the conduct of this event, including the responsibilities of the Captains and the volunteers. The following elements are stipulated within this Guide:
IMNA Staff will provide:
• Race Specific Boat Plan
• Emergency Plans
• Medical Operations Plans
• Rescue tubes
• Lifeguard whistles
• Communications (radios/flags)
• Training
The Captains report to the Swim Course Captain and their responsibilities included:
• Recruit the number of volunteers indicated
• Educate volunteers – job, times, functions
• Manage volunteers on race day
Captain’s positions include:
1. Swim Course Captain
2. Lifeguard Captain
3. Boat Captain
4. Kayak Captain
5. Dive Captain
6. Peeler Captain
Volunteers are to provide the “equipment required in accomplishing their area of participation. (Example: kayak, paddle, life jacket).”
Schedule and Timelines for Swim Course
The schedule and timelines call for the conduct of Captain meetings 4 months, 3 months, and 2 months out. During the race month, training was to be provided. The Wednesday of race week, a final risk assessment was required to be turned in. On race day, the swim course volunteers were to be on site at 5:45 AM and they were to be in place by 6:30 AM, with the swim underway from 6:45 AM to 9:20 AM.
Overall Swim Captain Job Description
• Responsible for the recruitment of qualified Swim Course Volunteers
• Serve as liaison between IMNA Swim Course Director and Swim Course Captains
• Recruit area volunteer Captains required per the Event Manual
• Provide radios to course captains on race day
KM was identified as the Lifeguard/Water Safety Captain and was responsible for the following:
• Responsible to the Swim Captain for the recruitment of all certified lifeguards
• Attend training sessions called by the Swim Captain
• Responsible for the recruitment of spotters
• Provide lifeguards with necessary information, including training and meetings
• Provide a detailed map of lifeguard locations and boat/board assignments to lifeguards and spotters
• Insure all lifeguards supply a current copy of certifications to be forwarded to Tim Johnson.
• The number of lifeguards required to man paddleboards and jet skis will be dependent on course type and distance, as per the specific boat plan.
• Make the final determination of personnel and equipment distribution.
The number of lifeguards identified for an ocean swim is 15 plus 8 spotters.
The Lifeguard Volunteers are responsible to the Lifeguard Captain:
• To provide water rescue for the support of the IMNA Swim
• To provide current copies of certifications.
• To attend training sessions called by the Lifeguard Captain
• Lifeguards will be positioned throughout the entire swim course according to the Lifeguard Captain’s plan to meet the boat plan
• Lifeguard will be on paddle boards and in boats
Spotter Volunteers
• Responsible to the Lifeguard Captain to provide extra eyes scanning the water for the support of the IMNA swim
• To attend training sessions called by the Lifeguard Captain
• To be positioned throughout the entire swim course according to Lifeguard Captain’s plan to meet the boat plan
• Will be on paddleboards and in boats
RR is again identified as the Boat Captain as well as the Swim Captain.
Boat Captain Responsibilities:
• Responsible to Swim Captain for recruitment of all power operated watercraft and operators (watercraft should be less than 25′ in length)
• To attend training sessions called by the Swim Captain
• Serve as liaison between the Swim Captain and the watercraft operators
• Provide operators with necessary information, including training and meetings
• To provide a detailed map of watercraft locations assignments to the operators per race specific boat plan
The number of small craft and operators were identified within the Guide as 8 small craft and operators and 6 Jet Skis with attached Rescue Boards.
Boat Volunteers
• provide platforms on the water for rescue…
• attend training sessions call by the Boat Captain
• Operators to be positioned throughout the entire swim course according to Boat Captain’s plan to meet the boat plan
KD was identified as the Kayak Captain and was responsible to the Swim Captain for the recruitment of all Kayaks and operators.
Kayak Captain Responsibilities:
• Attend training sessions called by the Swim Captain;
• To serve as liaison between the Swim Captain and the Kayak operators;
• Provide all operators with necessary information, including trainings and meetings;
• Provide a detailed map of Kayak locations assignments to the operators.
The number of Kayaks and operators identified were 24 kayaks and 6 kayaks/paddleboards.
Kayak Volunteers
• Responsible to the Kayak Captain to provide first response to initiate a rescue
• To attend training sessions called by the Kayak Captain
• To be positioned throughout the entire swim course according to Kayak Captain’s plan to meet the boat plan
• Responsible to detect swimmers in distress and initiating the rescue plan
KM was identified as the Dive Captain and was responsible to the Swim Captain for:
• The recruitment of qualified Dive Team for Search and Recovery;
• To attend training sessions called by the Swim Captain;
• To serve as liaison between the Swim Captain and the Dive Team;
• To provide Divers with necessary information, including training and meetings;
• To provide a detailed map of the Dive Team location;
• To work with the Swim Director to establish Standard Operating Procedures for search and recovery.
• To brief the dive team on all policy and procedures no later than two weeks prior to the race
Dive Volunteers
• To be responsible to the Dive Captain to provide dive services and to provide Search and Recovery Operations in support of the IMNA swim
• To attend training sessions called by the Dive Captain;
• To be positioned throughout the swim course according to Dive Captain’s plan to meet the boat plan;
• To be responsible for search and recovery of a lost swimmer;
• To assist as spotters on corners and at the swim start
The Staff Guide deals with Problem Swimmers and discusses 3 emergency situations:
• Recovery of a swimmer
• Swimmer down procedures
• Swim course medical
The Recovery of a Swimmer section states that in the event of an emergency, the athlete will be loaded onto the watercraft and the watercraft will transport the swimmer to the nearest of recovery locations, as per the Swim Course Medical.
The Swimmer Down Procedures state that the certification of the lifeguard will determine the Standard Operating Procedures (SOP) used in the event a swimmer is observed descending below the surface. It also requires the Lifeguard Captain to review the SOPs with the lifeguards.
The Swim Course Medical section states that the extract locations will be determined by the Race Director, the Medical Director, and Swim Course Director, and that ambulances will be stationed at the beach start area and the transition area. This plan also stipulates the need to assign a team of EMTs to be present at the swim portion of the event in accordance with the Boat Plan, as well as a medical tent at the beach, and ambulances to be stationed at the beach start area and the transition area.
The Star Fish Course Plan is shown within the Staff Guide (page 13) and is designed for a 2.4 mile swim. On page 14 of the Guide, it explains that this plan is based on a 30-second response time and that team training is required for all members on the water.
According to this Plan, the following equipment/personnel resources would be required:
1 kayak per 100 yards = 21 plus 1 lead and 1 last swimmer = 23
1 spotter every 250 yards = 9
1 lifeguard every 500 yards = 5
1 backup lifeguard every 1000 yards = 3
1 EMS boat crew every 1000 yards = 3
1 – 2 roving boat crews anchored inside the course.
The Ironman Florida Swim Course Guide has another section that lists additional persons in the role of Lifeguard Captain (TT), Boat Captain (JM), Kayak Captain (RB), and Dive Captain (KE). However, all the responsibilities and duties for these Captains are the same as previously specified.
According to my conversation with RR, he stated that he was not the Boat Captain, but rather, JM was. But, he also stated that KE, who is listed as the Dive Captain on the duplicate guide, could not have been the Dive Captain as she is not a diver, and if she was there, she was most probably in a kayak acting in the capacity as a spotter. RR also identified RB as the Kayak Captain, as listed on the duplicate guide, even though KD is listed on the first guide as the Kayak Captain. RR stated that KD was a Rescue Diver and couldn’t have served in the capacity as Kayak Captain.
BREACHES IN THE STANDARD OF CARE
1. Failure to properly supervise, guard, monitor, survey, and secure the swim area and competitor swimmers;
2. Failure to properly plan, organize & conduct the swim competition in a reasonably safe manner;
3. Failure to develop surveillance protocols for Lifeguards, spotters, boat operators, and EMS personnel stationed in and on the water;
4. Failure to train lifeguards, spotters, boat operators, and EMS personnel in surveillance protocols;
5. Failure to position lifeguards, spotters, boat operators, and EMS personnel to implement effective surveillance protocols;
6. Failure to establish proper procedures and protocols governing the response to specific emergency situations on/in the water;
7. Failure to train lifeguards, spotters, boat operators, and EMS personnel in proper surveillance protocols for victim recognition, and the response to specific emergency situations on/in the water;
8. Failure to provide sufficient supervision at the swim competition event for early recognition of emergencies and rapid response by rescue personnel;
9. Failure to provide a sufficient number of lifeguards, spotters, boat operators, and EMS personnel trained in water rescue and EMS protocols and procedures;
10. Failure to sufficiently research the oceanic and weather conditions to ensure that the conditions were safe for swimmers;
11. Failure to educate and/or inform the competitors of the air and ocean conditions that existed prior to the start of the race;
12. Failure to provide adequate safety, rescue and EMS equipment for use in rescue;
13. Failure to develop a Threat Assessment and Risk Management Plan;
14. Failure to implement the Risk Management Plan after identifying the hazards, risks and dangers associated with the conduct of this event;
15. Failure to cancel or suspend the competition when the weather and/or water conditions were unsafe;
16. Failure to pre-plan emergencies and develop Emergency Action Plans (EAPs), and Emergency Response Plans (ERPs), as well as an Incident Command and effective communication structure;
17. Failure to conduct training for all Captains and volunteers as required by the Staff Guide;
18. Failure to develop and implement a Boat Plan plan as required by the Staff Guide;
19. Failure to acquire the personnel and equipment resources as specified on the Starfish Aquatics Plan and failure to implement their use as per the Starfish Plan contained within the Staff Guide;
20. Failure to provide the required number of boats, kayaks, lifeguards, spotters, and jet skis as required by the Staff Guide;
21. Failure to develop and implement Standard Operating Procedures, including a Swim Course Safety Plan and a comprehensive Boat Plan, for lifeguards, boat operators, kayakers, spotters, dive team members, EMS personnel, etc.
22. Failure to develop and implement a Swim Course Medical Plan;
23. Failure to determine specific Extract Locations from the water for use during medical emergencies in or on the water;
24. Failure to stage ambulances at the beach start area and the transition area as described in the Staff Guide;
25. Failure to assign a team of EMTs to be present at the swim portion of the event in accordance with the Boat Plan;
26. Failure to establish a medical tent as stipulated within the Swim Course Medical Plan in the Staff Guide;
27. Failure to implement a 30-second response time and conduct tream training for all members on the water as specified within the StarFish Plan;
28. Failure to establish 3 EMS boat crews on the water as specified within the Starfish Plan;
29. Failure to establish roving boat crews inside the course as specified within the Starfish Plan;
30. Failure to issue and/or require lifeguards and spotters to wear polarized sunglasses.
31. Failure to place a medical boat on the swim course, staffed with EMS personnel and equipment, including oxygen administration, positive pressure ventilation equipment, airway management equipment, and an Automated External Defibrillator (AED);
32. Failure to develop and implement Emergency Response Plans to transport ill or injured victims in the water rot the designated medical boat for appropriate EMS intervention.
33. Failure to have a designated EMS crew on the beach equipped with oxygen administration, positive pressure ventilation equipment, airway management equipment, and an Automated External Defibrillator.
SUMMARY
The 2006 Athlete Information Guide states that “On race day, you will see an Ironcrew of nearly 4,000 volunteers ensuring you a safe and pleasant trip to the finish line.” And, “the safety of each swimmer is our prime concern….Visual aid will be provided by the lifeguards, divers, canoes and kayaks, buoys, and aquatic crafts that line the course.”
Based on my review of all the materials, including depositions, as well as my discussions with volunteers, competitors, and witnesses, it is evident this was not the case.
North America Sports, Inc., World Triathlon Corporation, and USA Triathlon developed, planned, organized, and conducted this competition event, and as part of their preparation, they developed and distributed the 2006 Ford Ironman Staff Guide. This Guide provided guidelines for the conduct of the swim portion of the Ironman Triathlon, including identifying roles and responsibilities for staff and volunteers, and the procedures that needed to be followed to assure the health and safety of all competitors.
However, this Guide failed to include critical elements, such as Standard Operating Procedures, Emergency Action Plans, Emergency Response Plans, Boat Plans, Medical Response Plans, Lifeguard Plans, etc. And, North America Sports, World Triathlon Corporation, and USA Triathlon failed to develop any type of accountability system to ensure the supervisory and training requirements were met, and they failed to ensure that the required personnel and equipment resources were available to assure the safety of all competitors who participated in the swim portion of this competition.
On November 04, 2006, 35-year-old Bernard Rice drowned while participating in the swim portion of the Ford Ironman Florida Triathlon. While swimming in this event, Mr. Rice experienced distress that went unrecognized by on-water safety and rescue personnel. His distress was unrecognized due to insufficient personnel and equipment resources, as well as a lack of training of the personnel who were designated to provide safety and rescue services during this event.
I’ve identified 33 Breaches in the Standard of Care. The Standards used to evaluate this matter were based on accepted practices utilized within the Aquatics Industry for lifeguard personnel, the Public Safety and Rescue field for Water Rescue personnel, as well as the Standards published within the 2006 Ford Ironman Staff Guide.
During Graham Fraser’s deposition, he repeatedly named Tim Johnson as the IMNA Swim Director and that Mr. Johnson was the one individual who was responsible for implementing the standards developed within the Staff Guide; for the conduct of the swim portion of the Triathlon; for the recruitment and supervision of safety and rescue personnel; and for the recruitment and deployment of safety and rescue equipment needed. Yet, very few personnel and equipment resources were available during the event, and no training or supervision had been provided to any of the safety and rescue personnel prior to this event.
By the time Mr. Rice’s distress was observed by one or several swimmers; on-water rescue personnel were notified of his distress; and the water rescue personnel responded to him, Mr. Rice had already deteriorated into cardiac arrest. Because appropriate Emergency Response Plans (ERPs) had not been established, Basic and Advanced Life Support care was delayed, both on the water and on shore. Mr. Rice died as a result.
From these breaches of the Standard of Care, it was clearly foreseeable that a death or serious injury could occur. As a proximate result, Bernard Rice died from an unrecognized immersion/submersion during the 2006 Ford Ironman Triathlon. This incident could have and should have been prevented had appropriately trained, qualified, and vigilant lifeguards, spotters, Water Rescue, and EMS personnel been on duty to recognize Mr. Rice’s distress and to appropriately intervene before his deterioration into cardiac arrest.
The Authority Having Jurisdiction (AHJ), namely, North America Sports, Inc. and USA Triathlon, had a responsibility to conduct a Threat Assessment and to determine the level of operational capability required to conduct this event and safeguard the athletes during the swim portion of the triathlon. The level of operational capability was outlined, to a great degree, in the form of the 2006 Ironman Staff Guide. The AHJ then had the responsibility to plan for the incident, to train for the incident, and to acquire the resources necessary to manage the incident. These actions, again, were spelled out to some degree within their Staff Guide, which provided job descriptions and responsibilities, as well as the need for training of Captains and volunteers prior to this event. It also included a list, description, and location of the personnel and equipment resources required to conduct this event and safeguard the athletes during their participation in the swim portion of the triathlon.
North America Sports, Inc. and USA Triathlon, and their representatives, had a duty to Bernard Rice to safeguard him during his participation in this event.
North America Sports, Inc. and USA Triathlon, and their representatives seriously breached that duty as previously described.
Bernard P. Rice drowned during his participation in the swim portion of the 2006 Ford Ironman Triathlon.
Bernard Rice’s drowning was directly caused as a result of the breaches in the Standard of Care of North America Sports, Inc. and USA Triathlon, and their representatives.