Miscommunication, poor planning, and lack of empathy relayed in review’s comments
UVic publicly released a review of the Bamfield crash today, conducted by Ross Cloutier, an expert in outdoor-related risk management with Bhudak Consultants Ltd. Cloutier’s review noted many areas of improvement are needed in terms of the university’s initial and ongoing emergency response.
The crash took place in September, on a Biology field trip to Bamfield Marine Science Centre (BMSC). The bus tipped over on the side of the road, and two first-year UVic students tragically passed away in the crash — Emma Machado and John Geerdes.
Machado dreamed of becoming a marine biologist and saw the trip as a highlight for her first-year. She moved to UVic from Winnipeg, Manitoba. Geerdes is from Iowa Falls, Iowa. He was a talented athlete, and had been asked to row and play soccer at UVic.
After the crash occurred, questions quickly arose. Students were travelling on a charter bus, on a rainy evening, at night. The newly released report speaks to these concerns and others related to the university’s response.
“We fully accept the review’s recommendations and are already working diligently to implement them to help prevent an accident like this from ever happening again, to strengthen planning for student trips off campus and to allow us to more effectively respond to critical incidents,” UVic President Jamie Cassels said.
Common themes of the report include miscommunication, lack of empathetic response
Ten students and sixteen parents were interviewed for the report, including the parents of Emma Machado and John Geerdes. Their comments in this report echo a lack of communication from the university.
“Our son called us from the hospital at 5:00 a.m. on Saturday,” one comment reads “There was no attempt from the University to communicate with us until the next Wednesday and this was by email only.”
Other comments further corroborated the university’s delayed response to the crash.
“We were not notified of the accident until seven hours after and that was by our daughter borrowing a cell phone from a doctor to call us,” another says. “Her phone went missing in the accident. It is an international call. We never were contacted by the University.”
“The University sent all the wrong compassion signals and were protectionist, shortsighted, illogical, and insensitive,” another comment from family in the report read.
A parent recounted how their daughter and another student were forced to leave the hospital with concussions.
“Both were minors from Ontario, they were given socks and scrubs from the hospital but had no shoes. They had no money with them,” the parent said.“They got Campus Security and said that they are being forced out of the hospital, with concussions, were minors, had no ID, and had no money. Security hung up on them.”
The report states that the families primarily want the university to pressure the government to pave the road leading to BMSC. Robert Dennis, chief councillor of the Huu-ay-aht First Nations in Bamfield, told the CBC after the crash that he has wanted that road paved for a long time. The Huu-ay-aht First Nation will continue to lead advocacy efforts, and will now be supported by UVic.
“Both families feel strongly that because the road is acting as an unofficial secondary provincial highway it should be made safe for public travel, and that with a concerted effort, the five large universities who own the BMSC have the political influence to get the road paved,” the report reads.
“The condition and suitability of the logging road as an essential corridor between Bamfield and Port Alberni continues to be a concern,” a press release about the report says. Cassels also noted that Transport Canada and the RCMP are completing their own investigation into the crash and the road itself.
The report establishes the lack of communication families recieved as a key failing of the university’s response to the crash.
“One of the greatest needs of parents, later described as having fallen short in their opinion, was for the University Executive to express appropriate empathy and compassion to families by acknowledging that the event, injuries, and deaths occurred,” the review says. “If there is a common theme being expressed by families, this is it.”
After the tragic crash
There was no cell coverage on the road. A student from the bus and a passing motorist drove 45-60 min towards Port Alberni to call 911. The inReach satellite communicator onboard the bus worked and reached the International Emergency Coordination Centre in Houston, Texas. They sent out initial information to outside agencies.
The crash occurred at 7:55 p.m. At 9:15, Port Alberni RCMP dispatched responders, including the BCAS (British Columbia Ambulance Service). A helicopter and plane attempted to reach the scene, but could not land because of the forest cover.
Seven students were transported to Duncan, and 40 were transported to Port Alberni. Those at the hospital in Duncan were given access to phones, and told they would not have to go on a bus for a while as that could bring about trauma for them. Individuals at Port Alberni had negative accounts of their treatment, and the report expressed that the hospital was overwhelmed.
By 2:00 a.m., Campus Security was informed there were fatalities, but the report says “details were sketchy and vague.” This was around the same time that students had cell service and began contacting their parents.
Parents left wondering where their children were
On Saturday, when some of the students returned to campus, the University realized the extent of their trauma.
“Students arrived without shoes or jackets; some were dressed in hospital scrubs; many had lost their packs, computers, and cell phones; many had not slept; most had no toiletry or personal care supplies; and many were in shock and traumatized,” the report reads.
At this point, some students had been picked up at the hospital by relatives. There was no record of where exactly every student was.
“The names of persons who went to either Duncan or Port Alberni, and of those who were airlifted to Victoria were not clearly tracked by the RCMP,” the review stated. “No one knew specifically where individual students were.”
“This caused untold work and delays on the part of Campus Security who spent most of Friday night trying to determine the location of each person, caused anxiety on the part of parents who were phoning Campus Security and the RCMP looking for answers, and required extensive follow up for the RCMP, who a day later were still phoning parents trying to determine whether they knew where their child was.”
It’s clear from the report that there was miscommunication and an inability for Campus Security to access information and act quickly. For instance, although Campus Security contacted the Biology department administrator at home on Friday night and received a list of all students on the trip, the list did not include emergency contacts for every student.
“The lack of good decision-making information contributed to the delay in activating initial response,” The report reads. “The delay was also due to being too conservative before acting and completely underestimating the significance of the event.”
The review also found that the University should have had a Site Response Team (SRT) and Emergency Coordination Centre (EOC). Instead, the university was reliant on other agencies, such as the RCMP, that were actually on scene. The information provided by the RCMP was “neither forthcoming nor clearly represented.”
“The University sent all the wrong compassion signals and were protectionist, shortsighted, illogical, and insensitive.”
The confusing miscommunications throughout Friday night and into Saturday morning left parents and students without critical information. Parents phoned Campus Security, and some travelled over on the first ferry in the morning from Vancouver to go to the hospital directly.
“Comments by these parents express how unhelpful Dispatch personnel were, and that although they were told they would receive a return phone call, they did not. Students expressed the same sentiment.”
Although the review states many campus offices have experience in responding to small crises, it also concluded that “no one at the University had dealt with an incident of this scale…and some elements of the response could have been handled better than they were.”
The review’s observations indicate the university was unprepared for a large-scale emergency like this, and that no university really would be.
Ongoing support strained the Office of Student Life
In the coming weeks and months, university staff in the Office of Student Life attempted to offer support for students and families. A Director took on this role, but the review states that a university executive should have been involved.
The director took on a significant amount of additional work, including an additional 200-300 emails a day, with support but no concrete acknowledgment of this new role. Families were distraught and angry, which took a continued toll on staff at the office.
“[Taking on these files] accounted for over 90% of their workload for the entire fall term and into the spring term while these staff continued to cover their regular caseload.”
“Many staff worked 16 to 18 hours a day, seven days a week, for weeks in a row to respond to needs, but few knew what was required, even within their own units,” the report states. “Staff exhaustion was real, and compassion fatigue a risk.”
Students expressed that they appreciated the empathy and academic support from the Biology department. However, as students were not “flagged,” other departments were less understanding. There was additional confusion between the Academic Advising office and the Biology department, as students received conflicting advice and sometimes may not have been deferred to Advising as necessary.
Counselling Services continues to provide ongoing trauma support to the students involved.
No trips to BMCS until recommendations implemented
The review offered 43 recommendations, all of which the university will implement. These include changes to pre-trip requirements, appropriate transportation and travel on the Bamfield Main road, emergency response protocols and student and family support.
“The university will strengthen pre-planning documents to require a more robust hazard assessment, make emergency contact information a requirement for course registration, review appropriate qualifications and training for trip leaders, and provide travelers with advance comprehensive information on trip logistics and risks,” a press release reads.
Cassels estimates that the Board of Governors will receive a report on the university’s progress annually.
“We regret that the sorrow, compassion and empathy that we felt was not communicated well to parents,” Cassels said. “This review provides us with important learnings that will benefit future students through strengthened policies and procedures and approaches to incidents in the future should they occur.”