By Shane Ohly Race Director

Introduction

Ourea Events organised the two 10Peaks™ events in 2017 and 2018 until the ownership of 10Peaks™ was passed to new owners ready for 2019. At the last 10Peaks™ event organised by Ourea Events in the Brecon Beacons, a series of events led to untreated water being supplied to some of the participants at one of the aid stations. As the Race Director, this has caused me to do some serious reflecting on our standard operating procedures, and in the interests of transparency and with a strong desire to share some learning points, I am now writing this article. The event took place on Saturday 14th July 2018, which was one of the hottest days of the year.

What exactly happened at the event?

The lead runner went through the Blaen Llia aid station at 08:00 and the two volunteers manning this location estimate that they ran out of their initial water supply after 2 ½ to 3 hours i.e. 10:30-11:00 in the morning. Their original water supply had been provided from Danywenallt YHA where the race starts and finishes, and then transported to Blaen Llia in jerry cans. As the original water supply at Blaen Llia ran low, the volunteers at this location opted independently to refill the jerry cans with water from a local stream.

In the meantime, at Race Control, we had been expecting a phone call from the Blaen Llia asking for a resupply at some point during the morning. The resupply water was ready in a vehicle standing off at the Storey Arms aid station, and this was part of our pre-event plan for keeping all the aid stations stocked with water.

In fairness to our two volunteers who took the decision to take the water from the local stream, they were both local and they had both drunk water (untreated) from that stream on previous occasions. With difficult communications (one of them would have needed to walk a short distance from the aid station to make a phone call to Race Control) and with the pressure of runners arriving regularly, they decided that topping up the water from the stream was the right thing to do. With hindsight, on an extremely hot day, I recognise that one could argue they had been set up to fail.

With no communications from the Blaen Llia aid station, and with time ticking by, we dispatched our resupply vehicle anyway, but without the prompt from Blaen Llia its arrival was delayed until 12:27. This delay resulted in about 100 runners passing through the Blaen Llia aid station and being provided with water that was untreated.

I was not aware that untreated water had been provided at Blaen Llia until a number of days after the event, when two concerned participants contacted the Ourea Events office to check what had occurred at the Blaen Llia aid station. It transpired that the two volunteers had informed some (but not all) participants as they passed through that the water had been supplemented from the stream.

What was our immediate response?

Once we had been contacted by the participants, I initiated a fact-finding investigation and spoke directly with everyone involved in the supply of water at the Blaen Llia aid station. This included the staff who had given the briefing to the event volunteers, the two volunteers at Blaen Llia itself, and the team involved with the resupply. I reviewed the recorded briefing given to the entire volunteer team, and the written instructions we handed out on the day to the various teams going out on the course.

Our immediate concern was whether there was a health and safety risk to the participants and, if so, how significant this was. We contacted the local Environmental Health department and an independent medical doctor with specialist wilderness experience for expert advice, which I would summarise as:

Yes, there are always health risks from drinking untreated water, but in this instance the likelihood of exposure to serious water borne pathogens should be low, and the majority of pathogens that cause notable ill effect (such as vomiting and/or diarrhoea) would have occurred in first 24-48 hours after exposure.

Based on this advice and because a number of weeks had already passed since the event by this time, and because there had been no reports of any illness, I decided there was no pressing need to contact the participants directly. However, we arranged for some independent testing of the stream water at Blaen Llia and made some immediate changes to our standard operating procedures. The changes to the standard operating procedures shifted the responsibility of ensuring that potable water is available at aid stations firmly to the Race Director. Rather than having a ‘load list’ of provisions to be taken to an aid station (that would include for example 250L of water), the ‘provision of water’ was added to the Race Director’s list of ‘Go / No Go’ criteria that must be ‘signed off’ before the race is started.

Water testing

The water testing was carried out by an independent water testing laboratory and confirmed that water tested did not meet the specification required by the Private Water Supply Regulations, which was the standard we tested against.

Obviously, the water tested was not the same as the water supplied on the day of the event, and it would never be possible to go back in time to test this water. However, the test results were indicative of the quality of the water in the steam and they showed an unacceptable number of coliform bacteria in the water.

Coliforms are a type of bacteria that are present in the digestive tracts of all animals, and therefore found in their faecal waste. Coliforms are tested because they are easy to identify and are usually present in larger numbers than more dangerous pathogens, and as a result, testing for coliform bacteria can be a reasonable indication of whether other pathogenic bacteria are present.

Coliform bacteria include E. coli and the presence of E. coli in water is an indication of recent sewage or animal waste contamination. Given the location of the Blaen Llia aid station, sewage contamination was unlikely and animal waste was probably the cause of this result. The presence of coliforms in water may not be directly harmful, and does not necessarily indicate the presence of faeces, however it does indicate an increased likelihood of harmful pathogens in the water.

More weeks had passed by the time we got the water testing done and the results back, and still there were zero reports of any illness from any participants despite much correspondence (email, social media etc.) and generally glowing feedback about the event. Therefore, due to the passage of time since the event, the lack of any reported illness, and the healthy adult demographic of our participants, I decided not to issue any generic health warning to all participants.

However, I have reflected on that decision and decided that it is not in keeping with my own very transparent style of Race Director reports and relationship I wish to have with the participants at my events. This is one of the reasons I am now publishing this article.

Drinking water choices

At many events like mountain marathons and fell races, drinking water taken directly from streams is common practice. However, at these types of events, the organisers generally do not intend to provide water on the courses and this is clearly communicated to the participants pre-event. Therefore, the onus is on the participants to be self-sufficient in whatever manner they deem fit.

Some participants carry water in bottles or hydration packs, others choose to drink directly from the streams as they go, and some treat water from streams by filtration or with chemicals before consumption. Personally, I am quite comfortable to drink directly from streams, but I recognise that this is entirely my own choice and I exercise my own dynamic risk assessment before drinking anything.

At the 10Peaks™ Brecon Beacon event, there would have been every reasonable expectation from the participants that the organiser would provide potable water at the designated aid stations.

Taking responsibility

As the Race Director, I want to reiterate that there was a plan to provide potable water to all the participants, at all the aid stations on that day. It was a plan that had been tested and proven to work at this event in previous years. The main difference at this event was the hotter than usual temperature. Despite clear instructions and plans about the provision of water to the participants at the Blaen Llia aid station, something unexpected occurred: the human factor.

However, taking responsibility for the event is part of the role of the Race Director and it would be way too easy to apportion blame to the volunteers at this location, and entirely miss the opportunity to improve our standard operating procedures for the future.

The human factor

The Health and Safety Executive guidance on the human factor makes it clear that most work place accidents occur because of the human factor (aka human error). These errors are often characterised in three ways: a) Lapses (actions not planned); b) Mistakes (actions not correct); c) Violations (intentionally doing something not instructed, but usually well intentioned). In all three cases, the onus is on the business to put in place systems that reduce the likelihood of these incidents occurring, and as a direct result of the 10Peaks™ event and my discussions with the two participants who raised the initial concerns, we have and are making the changes described below.

Summary of changes to our standard operating procedures

• Provision of Potable Water – Over the 2018/2019 winter months, we have been working on a new standalone policy, risk assessment and method statement for the provision of potable water at all our events. This policy is being rewritten from scratch with a careful review of all the current good practice guidelines and legislation, and how they are implemented at our events.

• Improved Water Consumption Prediction – We have taken data from many of our events over many years and created a matrix of water consumption. This now allows us to look back at historical data and see how much water was consumed by x number of participants, which in turn enables us to make more accurate predictions of water requirements. A healthy margin of error is added to our estimates. As we accumulate more and more data, these predictions should become more and more accurate.

• Race Director’s Responsibility – As previously mentioned, the responsibility to check that there is sufficient water on the course (for the events where we provide water in this manner) has been promoted to the Race Director’s list of ‘Go / No Go’ criteria that must be ‘signed off’ before the race is started.

• Labelling of Jerry Cans – All Ourea Events jerry cans designated for the purpose of holding drinking water will have a permanent ‘drinking water only’ sticker added to them, so that this aspect of good practice will be much clearer to everyone involved in the provision of safe drinking water.

• Improved Briefing – The importance of the provision of safe drinking water has been specifically added to the event team briefing, and the written instructions issued to the teams managing our support points and aid stations have been updated.

• Participants’ Choice – All our event websites have been updated to state clearly what the provision of water at each event will be, so that participants are fully informed pre-event. For example: 1) Water at the Event Centre is mains water; or 3) No water is provided at the Overnight Camp and the participant is responsible for sourcing and treating their own water; or 4) Water at the support point is mains water supplied in jerry cans / bowsers.

Conclusion

I would like to state that I am genuinely sorry that our own very high standards were found wanting on this occasion, resulting in an unforeseen health and safety risk. For me personally it has been painful to discover that there were weaknesses in our planning and preparation for this event. That said, please be assured that many important lessons have been learnt, which will be incorporated into our event management plans in the future.

Finally, 10Peaks™ is now being organised by the team at Kong Adventure due to Ourea Events rationalising our event portfolio in order to focus on our large international events – Berghaus Dragon’s Back Race®, Cape Wrath Ultra® and Salomon Skyline Scotland™, and mountain marathons all of which I remain personally very passionate about.

I really hope that this frank and honest discussion about the 2018 event does not put anyone off entering the 2019 race and I wish Kong Adventure every success with the two 10Peaks™ events.