October 1, 2016 The Drowning of Tony Lot

On May 23, 2006, 18-year-old Tony Lot, a senior at Venus High School in Johnson County, drowned while on a class trip to Burger’s Lake in West Fort Worth. Tony had been swimming with his classmates at the school’s annual senior day – just two days before he was to graduate.

The students reportedly had been swimming in about eight or nine feet of water while jumping off a pier in the middle of Burger’s Lake. One boy noticed Tony’s body at the bottom of the lake and alerted a nearby lifeguard who had been patrolling the lake in a row boat. It is important to note that when Tony was removed from the water, there were reports that he was wearing pants and a shirt. It is unclear who rescued Tony and towed him to shore. Lifeguard K testified that he rescued Tony and towed him to shore, with the help of Lifeguard B. However, one of Tony’s classmates stated during a news report of this incident that he and his friends rescued Tony from the lake and towed him to shore.

Once on shore, CPR was administered by lifeguard personnel and maintained until fire and EMS units responded to the scene. Mouth-to-mouth rescue breathing was administered by one of the lifeguards, as a Personal Resuscitation Mask was not immediately available, while another lifeguard performed chest compressions. Lifeguard K ran to the lifeguard room to obtain a mask so that they could perform mouth-to-mask rescue breathing and chest compressions.

Upon arrival of Fire and EMS services, resuscitation efforts were maintained and Tony was then transported to Harris Hospital, with CPR en-route, and was eventually pronounced dead at the hospital.

TESTIMONY OF LIFEGUARD K

Lifeguard K was hired by and employed as a lifeguard by Burger’s Lake, even though he had no professional training and/or experience as a lifeguard. His limited training was that of a Navy Rescue Swimmer by the Navy. This training did not include any information and/or skills on hazard and risk assessment around the aquatic facility; patron protection and surveillance protocols; lifeguard operations; victim recognition; etc. Lifeguard K had been hired as a lifeguard in 2005, and was provided an orientation at that time. However, Lifeguard K admitted that no pre-service training was provided him during his second year (2006) as a Lifeguard for Burger’s Lake. Meanwhile, Lifeguard H, another lifeguard on duty at the time of the incident, had similar training to Lifeguard K, was not appropriately trained and certified either, and like Lifeguard K, was not certified or qualified to work as a lifeguard at Burger’s Lake.

Besides not being trained and certified as a Lifeguard, Lifeguard K was also not appropriately trained and certified in CPR for the Professional Rescuer, or its equivalent. Lifeguard K was trained and certified by the local fire department in Adult CPR only. This curriculum only includes skills and knowledge in Rescue Breathing, First Aid for Foreign Body Obstruction of the Airway, and CPR. It does not include the use of airway adjuncts or positive pressure ventilation devices (Personal Resuscitation Mask and Bag-Valve-Mask Resuscitators), nor does it include instruction in the use of an automated external defibrillator (AED).

Just prior to the recognition of Tony’s submersion by a patron, Lifeguard K was stationed as a lifeguard in a row boat positioned within the swimming area where Tony was located. The purpose for the use of a row boat is to intervene in a rescue in a timely manner. However, the use of the row boat provides no surveillance advantage, especially when it places the lifeguard at a lower elevation than that of a lifeguard stand; it requires the lifeguard to scan a zone of responsibility greater than 180 degrees; and it distracts the lifeguard from his/her surveillance responsibilities because the lifeguard is required to constantly maintain the boat in a stable position or move the boat while trying to maintain patron protection and surveillance responsibilities, without running into swimmers.

Prior to Lifeguard K being assigned to the boat station, he had been in stand #3. According to Lifeguard K, the lifeguards are typically provided with a 15-minute break after about 3-hours on the stand. This is too long a period of time to be effective in providing constant and continuous surveillance as a lifeguard.

When Lifeguards K and Lifeguard H swam Tony to the beach, although the head Lifeguard and others were supposedly ready to administer CPR they did not have any type of positive pressure ventilation device (i.e. personal resuscitation mask, personal resuscitation shield, or bag-valve-mask resuscitator) available. As a result, after performing the rescue and swimming Tony to shore, Lifeguard K then had to run to retrieve a mask for use during the resuscitation effort on Tony.

Lifeguard K failed to observe Tony at or below the surface of the water. He was wearing contacts at the time of the incident, but doesn’t remember whether or not he had sunglasses. Burger’s Lake has no policy regarding the use of sunglasses by their lifeguards and does not provide sunglasses to their lifeguard personnel. Once Lifeguard K was advised of Tony’s situation and location, Lifeguard K had to use the patron’s goggles in order to enter the water to search for Tony, because masks, fins, and snorkels were either not immediately available or were not provided for use by lifeguard personnel.

Once Tony was removed from the water and CPR was administered, the level of basic life support care provided by the lifeguards was no better than what any CPR trained citizen could provide. There was no automated external defibrillator (AED) available, and as far as Lifeguard K knew, no one was trained in the use of an AED. However, if the Lifeguards were trained and certified in CPR for the Professional Rescuer through the American Red Cross, they would have been trained and certified in the use of an AED. Lifeguard K stated that the Personal Protection Equipment and Personal Resuscitation Masks were kept in the lifeguard room. He admitted he didn’t know why the lifeguards weren’t required to carry their own mask to have it available for a resuscitation emergency. If the lifeguards were trained and certified in CPR for the Professional Rescuer, they would have been issued a Personal Resuscitation Mask during their training course for use in the performance of their practical skill evolutions. When Lifeguard K was asked about an airway suction device, oxygen administration equipment, a Bag-Valve-Mask Resuscitator (BVM), and the AED, he stated he was not aware whether this equipment was available at Burger’s Lake and that he was not trained in the use of this equipment.

When Lifeguard K was asked about emergency drills, he did not recall participating in any emergency drills prior to this incident. Lifeguard K also stated he was never provided any written Standard Operating Procedures (SOPs), Emergency Response Plans (ERPs), or Emergency Action Plans (EAPs). Furthermore, he was never provided any specific training by Burger’s Lake employees or officials in patron surveillance protocols.

Lifeguard K had no knowledge of the 10/20 Rule and when asked what a drowning victim looks like, he stated, “They holler. They splash. They might gulp.” Had he participated in an appropriate lifeguard training program, he would have learned that victims do not wave for help; they don’t call for help; and in many cases, it may appear like they are playing in the water, when in reality, they may be engaged in a life and death struggle to keep their heads out of the water in an attempt to breathe.

TESTIMONY OF JIMMY DENT

According to Jimmy Dent, since he purchased Burger’s Lake in 2000, at least 2 other previous drownings had occurred at Burger’s Lake, prior to the submersion and drowning incident of Tony Lot. And, he believes there were 4 drownings at the lake while the lake was owned by previous owners. This is clearly indicative of the need to perform a comprehensive Threat Analysis of the facility to determine the most appropriate operating procedures and deployment of lifeguard personnel to safeguard the public engaged in aquatic recreational facilities at the facility. However, Mr. Dent admits that he has never conducted, or had conducted, a Threat Assessment to determine the number of lifeguards necessary to provide patron protection or to determine the most appropriate lifeguard-to-patron ratio that should be used at Burger’s Lake. According to Mr. Dent, the only assessment that was done was based on the number of cars in the parking lot to prevent exits from being blocked in case of a fire emergency.

At the time of the incident, he estimates there were 80 – 88 guests in the park. Depending on crowds, Mr. Dent stated there could be anywhere from 8 – 13 lifeguards on duty.

Neither Lifeguard H or Lifeguard K were appropriately trained and certified as lifeguards. Neither had participated in an American Red Cross Lifeguard Training course, and Lifeguard K was not trained and certified in CPR for the Professional Rescuer. Yet, the Burger’s Lake website states, “A complete staff of certified lifeguards is on duty at all times.” One other person, Lifeguard B, serving as a lifeguard was an EMT, but was not trained or certified either as a lifeguard.

When Mr. Dent was questioned about the Navy Rescue Swimmers and EMT certified personnel who were not trained and certified as lifeguards, even though they were working in the capacity as lifeguards, he responded, “Their qualifications are much greater than that you receive from the American Red Cross.” This is absolutely false in that these individuals were not trained in lifeguard operations; patron surveillance protocols; victim recognition; hazard and risk assessment; etc.

At the time of the incident, there were 8 lifeguards on duty, with 1 lifeguard (Lifeguard K) in the boat, 2 on break (Lifeguard S1 and Lifeguard S2), 1 Roaming (Lifeguard B2), 1 on the Benches/Rockwall (Lifeguard S3), and 3 in lifeguard stands (Lifeguards B, H, and M). Lifeguard stations #5 and #2 were unoccupied, and at least two of the lifeguards in stands (Lifeguard H & B1) were not trained and certified as a lifeguard, nor was Lifeguard K who was situated in the boat. Although Mr. Dent stated that Lifeguard S3 had been assigned to the Benches/Rockwall, according to Lifeguard S3 he had been shoveling sand when the incident was recognized.

Mr. Dent stated that Lifeguard B was an EMT and had been at Burger’s Lake for many years, but that “it was not his primary job to be a lifeguard.” Yet, he was serving in this capacity at the time of the incident and was positioned in Lifeguard stand #3 when Tony’s body was discovered.

Tony’s body was discovered within the Zone of Responsibility for the Boat Lifeguard, because Lifeguard stands #2 and #5 were unoccupied, according to Mr. Dent, because of the low crowd of guests.

The year of the incident (2006), there were 2 Head Lifeguards that would alternate. According to Mr. Dent, the duties of the Head Lifeguard included:

1. Oversee the other lifeguards;
2. Determine the rotation of lifeguards; and
3. Determine the lifeguard stations needed

However, Mr. Dent, as well as his Head Lifeguards did not require all Lifeguard stations to be manned. At the time of the incident, both Head Lifeguards were on duty and were sharing the Head Lifeguard duties and responsibilities.

The Head Lifeguards were not required to participate in any additional training to qualify them for their positions. According to Mr. Dent, the prerequisites for the Head Lifeguard was, “had been there for many years and had a lot of lifeguard experience.”

Mr. Dent confirmed that there were no written Lifeguard Standard Operating Procedures (SOPs) or Emergency Response Plans (ERPs), but that there were periodic drills (every 4 – 5 weeks) that were staged, although none were documented. He further admitted there was no in-service training that was conducted for the lifeguards. He further admitted the Lifeguards were not provided or required to wear sunglasses while providing surveillance; that there was no vision testing of the lifeguards prior to being hired; and there was no patron surveillance training conducted.

Mr. Dent stated he did not know that CPR for the Professional Rescuer certification was required of the lifeguard personnel and he didn’t know that Lifeguard K was only trained and certified in Adult CPR.

Although Mr. Dent thought the lifeguards were trained in oxygen administration procedures, he admitted they did not have a Bag-Valve-Mask Resuscitator; they did not have oxygen administration equipment; they did not have an airway suction device; and they did not have an AED.

When Mr. Dent was asked about masks, fins, and snorkels for use by the lifeguards, he stated this equipment was kept in the bathhouse, but that lifeguards were not provided training in the use of this equipment.

Mr. Dent admitted that Burger’s Lake did not have any rules and regulations regarding proper swimming attire for guests. He also admitted that Lifeguards were allowed to sit on the ground, adjacent to the lifeguard stands.

TEXAS DEPARTMENT OF HEALTH STANDARDS FOR SWIMMING POOLS AND SPAS

These standards clearly indicate that all lifeguards “shall hold a current ARC Lifeguard Training certificate” or the equivalent certification from an aquatic safety organization, which also includes ARC Adult, Infant and Child COR and Community First Aid or its equivalent. Yet, when this incident occurred, at least 3 of the individuals working as lifeguards (i.e. Jason Hatton, Chad Kirkland and Les Burgess) at Burger’s Lake were not certified as lifeguards and had not participated in or been trained by the American Red Cross or any other aquatic safety organization in Lifeguarding. Furthermore, although Les Burgess was certified as an Emergency Medical Technician (EMT), Chad Kirkland was only certified in Adult CPR, and as a result he had no training in the use of a Bag-Valve-Mask Resuscitator or an AED.

These standards indicate that lifeguards should be given an assigned zone of responsibility and that while conducting surveillance, the lifeguards “shall not be assigned duties that would distract their attention from proper observation of the users….” However, according to Sanderson, although he supposedly had been assigned a surveillance station, he was engaged in shoveling sand when the incident was recognized.

The standard states the number of lifeguards shall be adequate to provide supervision, continuous surveillance, and close observation of all bathers, and that lifeguard stations “shall be placed in locations to reduce sun glare on the water, and in positions which allow complete visual coverage of the pool…within a field of view no greater than 90 degrees on either side of a line of sight extending straight out from the platform or chair.” However, based on my analysis of the facility photos, it is evident that lifeguard stations were not strategically positioned and that the placement of several lifeguard stands required surveillance of a zone of responsibility greater than 180 degrees.

The standard states that lifeguards shall receive training in the application of effective emergency procedures and that this training shall be reviewed as necessary and kept current. There is no documented training of any formal pre-service or in-service training or of any emergency drills that were conducted at Burger’s Lake.

The standard states that an Emergency Action Plan (EAP) must be in place and that performance audits are conducted. Furthermore, it specifies that a pre-season training program and a continual in-service training program be conducted. However, there was no written EAP, and there was no formal pre-service or continual in-service training programs conducted for the lifeguards, nor were there any performance audits conducted.

The standard also discussed the need for lifeguards to be rotated and provided breaks in order to maintain their vigilance. Yet, the rotation system used at Burger’s Lake did not adhere to any recommendations of such organizations as the American Red Cross or the YMCA.

Lastly, the standard states that management shall maintain a current file of each staff person’s current certification, including expiration dates. Yet, the certifications of several of the lifeguards did not show course completion dates, and several of the lifeguards did not meet the minimum certification requirements established by this standard.
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Note: As of 2007, Burger’s Lake was sold to a new owner.