WOW closing the slides makes about as much sense as banning dark swimsuits. I sure hope the study pointed out the obvious issues of lifeguard inattention, pool clarity etc...

Adding more guards without addressing training issues or water quality will simply cost more money while adding little to the safety margin. It's not rocket science, yet we fail miserably so often.

There is such a disconnect between the people who "get it" and those who remain clueless. Of course those reading this post are most likely in the first group and those in the second do not even know about this site.


Bob Pratt

Great Lakes Surf Rescue Project

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I agree 100% that the disconnect is the problem. How do we get out and educate those who don't know about all the tools, resources (like this site), educational opportunities and best practices out there. I hate to say that there will be many who do not step up until their local codes make them. 

"We had a drowning in the pool...Well better add lifeguards...The person who drowned in our pool went down the slide...Better close the slide until someone tells us it is safe..." (all of this at unnecessary expense)

Has anyone in the Mass. area who is on this site or any where else offered to go in there for little charge (or free) and tell them what happened?  You opened your pool when you can't see the bottom. Some incident happened which caused a person to become unconscious in your pool and they died. Your lifeguards couldn't react because they couldn't see what was in the water. I don't care how many lifeguards or pool managers you have on duty, if you can't clearly see the bottom money won't fix the problem of being able to protect a pool until you clear up the water. 

This tragic incident has been so botched on every front it is hard to come up with adjectives or analogies to make humor out of it. From the operational issues that caused this, to the media response from the agency it has been bad. I'd love to be told I am wrong and I just missed their responses and how they did handle this appropriately after the event.  

You both make great points, here. Thanks for alerting us to the findings, Bob and for the great commentary from both of you... I hope others aquatic pros weigh in on this subject... Would either of you be interested in expanding on your thoughts for an opinion column in AI? Let me know!

Wow, this just makes me think..... 

MASS Safety Expert "Lets distract the public by closing the slides down, im sure that will keep us off the hot plate till everything blows over."

Many of those that post to AI Connect could figure this out at home with about two days of research.  Here is a thread that has a few findings

Found another report..

Here's an analogy, Lets take the train off the track, so speeding cars crossing the intersection aren't hit by it.

I found a link to the full report. I'm curious to dig through the actual report.

Link to Full Report

Thanks for posting the link Joe,

After a first "once over" it looks filled with typical hyperbole. It avoids terms like ‘negligence’ or ‘incompetence’ and concludes that “Marie Joseph’s drowning was a tragic event that might have been prevented”. “MIGHT” have been prevented?? WOW we have such a long difficult road ahead.

This case should be used as a springboard for water safety professionals everywhere. WE failed, you and I just as much as the pool operator at this facility. No, not in this particular instance; those failures were so clear, so incompetent, and so negligent. But we have failed as an industry to police ourselves so that this was allowed to happen.

Let me begin this rant with the case in question:

There are several factors that lead to this death; the biggest and most important was water clarity. You could not see the bottom of the shallow end let alone the deep end. This single factor may have allowed recognition of a problem in time for a rescue. At the very least the body should have been seen at close of the pool. There were 4 guards and an asst. manager on duty at the time of the drowning. On page 20 of the Red Cross Lifeguarding Manual 2007 under the heading “Typical Items Found On A Safety Checklist” it states “The bottom of the pool, attraction or the main drain can be clearly seen”. But on June 26th those 5 people were either unaware or afraid or coerced into opening a pool where they could not see the bottom of the pool in the shallow end. Shame on them and shame on their instructors and their I.T.’s. I sincerely hope anyone that I trained would have the guts to refuse to open the pool or at the very least discreetly call me and let me create a firestorm at the facility.

The recommendation: Require the use of a Secchi disk and require "in-water" pool checks. In my 30 years of water safety I have seen one Secchi disk. It was at the bottom of a file cabinet and no one knew what it was except a limnology major that used one in the local river. There is no need for a Secchi disk, If you cannot see the bottom of the pool close it! Furthermore, if you CAN see the bottom; there is no need for “in-water” pool checks.

In addition to the water quality issue you have a slide with a single operator and with multiple areas of responsibility. Chalk that up to budget cuts. Again if you can’t safely use the slide; close it down. Adequate staffing may have resulted in a rescue but the combination of poor water quality and inadequate staffing made that unlikely.

Ms. Joseph could not swim.

Let that sink in a second.

She used a slide to enter the deep end of the pool. She could not see the bottom and might not have known how deep the water was. There is no mention in the report about swim testing patrons and only a vague reference to a lack of signage. Had the water been clear I doubt she would have gone down the slide. The recommendation: Close the slides (at all the pools), reduce the level of the pools to 5’6” and increase staff. If you increase the staff you might not need to close the slides and if you clean up the water you certainly don’t need to change the pool depth. Hopefully we will not see an increase in spinal injuries because they made all the pools shallow.

There is also talk of reorganizing the structure of the government agencies and hiring year round pool staff rather than the all seasonal positions. These are the best recommendations and lead me to part 2 of my rant.


Quite candidly: WE STINK!

She came to the surface twice as she was drowning. It took a total of seven seconds. In the 1960’s Frank Pia postulated the Instinctive Drowning Response and was spot on! We know drowning is swift and silent. No yelling/ no splashing and yet 50 years later we still don’t adequately train guards to recognize drowning for what it is. Look at the new Red Cross book…too many of the “victims” have their arms out of the water. If the National Red Cross can’t portray drowning realistically how can we expect our lifeguards to recognize it?

Drowning is the second leading cause of accidental death in children. The vast majority of these are preventable; easily preventable. Drowning is the 4th leading cause of death for all ages. The vast majority of these are preventable; easily preventable. We need to stand up across the board, every one of us and demand that water safety be taken seriously. Oh I know what you’re saying: you sit on this committee or belong to that organization or started this foundation.  But that’s the reason we are so ineffective: we have no leadership. The VGBA people don’t care about this case, neither does USLA nor YMCA nor a hundred other “water safety” organizations.

At the 2012 National Drowning Prevention Alliance Symposium there were dozens of foundations, many dedicated to lost loved ones. There were several large organizations with a narrow focus US swimming for example. Incredibly, several of the major organizations didn’t even show up (USLA; even though it was in their back yard) or just sent local representatives (Red Cross). Ironically the National Safe Boating Congress was meeting the previous three days yet neither group thought about tying the symposiums together.

We need to start working together. We can no longer afford to be focused on a single aspect of water safety. Red Cross instructors must become advocates for residential barriers. The USLA needs to support learn to swim programs. You need to move outside your comfort zone and work with other ‘partners’. ISR needs to support the YMCA and vise versa. We need SOMEBODY (NDPA?) to step up and unite us in a coordinated effort.

And while I’m at it, we need to all start calling BS on some long held practices. Let’s start with single guard facilities. Or Red Cross (Ellis, YMCA etc…) guards at surf beaches. How about swim at your own risk beaches? When and how did that become the norm? I know, I know those are big issues WAY bigger than we can tackle today… so here’s what I’m gonna do, here’s how I’m going to make a difference in my own back yard: one of the pools I frequent has poorly trained and poorly supervised guards. I’m going to send the CEO a copy of this along with a brief outline of the shortcomings (and possible solutions) at their pool. Next time I'm at the lake I'm gonna remind that boater that his child should be in a lifejacket. I’m going to do it because I’m a water safety professional and I can no longer stand idly by and let another tragedy like Marie Joseph happen.

If I have to do this one pool at a time that's what I'm gonna do....

Anybody wanna join me?


Thank you so much for the link. It is too important not to give it full attention.


Contrary to the emerging trend critical of the investigation, I found the document insightful and a proper case study for what not to do.

No doubt there is good reason to both cringe and be outraged by what the document reveals. It is understandable that its reading might give rise to utter incredulity or even despair. But all this aside, and in spite a writing style that is at times stilted, perhaps clunky, it nevertheless delivers with clinical embrace a balancing of facts.

Good investigations by design must examine the facts and make no legal evaluation of those facts. “Negligence” and “incompetence” are words not material to any investigation as these are legal constructs to be determined in a court of law. To interject such terms would make an investigation overreaching, and quite predictably, the scorn of any legal department. Recognizing the impulse to leap to conclusion, it doubtless is the equivalent of a police report referencing an incident involving a lone, knife-wielding, blood-splattered man found in a dead-bolt locked room with a lifeless body inside, as a “suspect.” It is a clear case of understanding what cannot be stated in public.

This incident should be fodder for teachable moments we can all take away. Some that come to mind include:

  • It is not enough to have policies and procedures. These are effective only if they have teeth. Commitment to safety starts at the top. The fact that upper management would give directives that are at variance with policy is in itself detrimental to the work safety culture because these lead to what risk analysts call “routine violations” – behavior that is rewarded when an incident does not occur, and thus reinforces negative behavior for the future. This is why centralized command and control is preferable over a decentralized structure because it creates a more insular work culture by keeping in check mission objectives.


  • An organization comprised of full-time staff is preferable over part-time staff because it creates a stronger “psychological contract” between the worker and organization that strengthens professional commitment and increases operational expertise.


  • As the economy continues to degrade, executive management will be tempted to reduce staff and training while expecting performance outputs to remain unchanged. (In this case, requiring staff to maintain the same operational hours while reducing personnel.) This tendency leads to “exceptional violations” – when staff is forced to meet contradictory demands that cannot be met without violating one or more stated objectives.


  • Safety is complex and systems reliant. Its complexity is proportional to the size of the operation. All parts must be interlinked with built-in redundancies (checks and balances) for the whole to be reliable.

I cannot say that I agree with every observation made in the report, nor that all the recommendations proffered make complete sense. And certainly, I am no apologist for the egregious conduct committed by the pool staff, but I am always leery to the blaming of staff for the lack of a safety culture since this is the province of upper management.


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