INVESTIGATION REPORT

RELATING TO DROWNING OF
LEWISTON MIDDLE SCHOOL STUDENT
AT RANGE POND STATE PARK
ON JUNE 12, 2018

Daniel C. Stockford, Esq.

Brann & Isaacson
184 Main Street
Lewiston, Maine 04243
June, 2018

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 TABLE OF CONTENTS

INTRODUCTION AND DESCRIPTON OF INVESTIGATION PROCESS……………….3

SUMMARY OF FACTS RELATING TO RANGE POND STATE PARK INCIDENT……4

EVALUATION OF FIELD TRIP PROCEDURES ………………………………………….9

RECOMMENDATIONS……………………………………………………………………..11

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 INTRODUCTION AND DESCRIPTION OF INVESTIGATION

Lewiston Middle School student Rayan Issa drowned at Range Pond State Park in

Poland, Maine, while on a school-sponsored field trip on June 12, 2018. The decision to conduct

an investigation of the incident was promptly made by Lewiston Public Schools Superintendent

Bill Webster. Because the incident involved the death of a student, and because the investigation

involved issues relating to appropriate field trip policies and procedures, Superintendent Webster

made the decision to appoint Brann & Isaacson to conduct the investigation. The mandate given

to Brann & Isaacson was to:

· Review the events of June 12, 2018 that preceded the death of Rayan Issa.

· Make recommendations for implementation by Lewiston Public Schools to prevent

similar incidents from occurring in the future.

· Prepare a report to the Superintendent of Schools, to be made available to the public,

disclosing the facts and recommendations resulting from the investigation.

The investigation consisted of two parts, a fact gathering stage, and a process for

reviewing the facts and developing recommendations. Interviews were conducted of the 11 adult

chaperones who participated in the field trip. This included attending interviews of all of the

adult chaperones that were conducted by detectives from the Androscoggin County Sheriff’s

Department on June 13, 2018, the day after the incident. Interviews of five students were

conducted by Brann & Isaacson on June 18, 2018, and additional interviews of seven of the adult

chaperones were conducted by Brann & Isaacson on June 19, 2018. Brann & Isaacson also

gathered and reviewed relevant documentation from the Lewiston Public Schools, including

existing field trip policies, field trip approval forms, permission slips, and rosters of students who

participated in the field trip.

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 The second part of the investigation consisted of review of the facts and development of

recommendations for the Lewiston Public Schools. With permission from the Superintendent,

Brann & Isaacson consulted an independent expert on aquatic safety, Carrie Bonnefond, who is

CEO of Lighthouse Health and Safety. Ms. Bonneford and her company provide training and

consultation services regarding aquatic safety to businesses, schools and summer camps

throughout Northern New England. Ms. Bonnefond was asked to provide recommendations

regarding best practices for conducting and supervising youth water activities. Brann & Isaacson

also reviewed policies and procedures for water-based activities developed by other

organizations, including the YMCA, YWCA, Boy Scouts and Girl Scouts, as well as guidance on

aquatic safety and activities developed by the American Red Cross.

The independent expert assisted in development of the recommendations contained in

this report. The organization and wording of the report are those of Brann & Isaacson, however,

and do not constitute a verbatim rendering of discussions with the independent expert. This

report summarizes the investigation and concludes with recommendations for implementation by

the Lewiston Public Schools.

SUMMARY OF FACTS RELATING TO RANGE POND STATE PARK INCIDENT

The June 12, 2018 field trip to Range Pond State Park was organized by the 7th grade

Green Team at Lewiston Middle School. The Green Team is one of three teams of students and

teachers in the 7th grade at Lewiston Middle School. The Green Team previously had conducted

a field trip to Range Pond State Park in June, 2017. In April, 2018, the Team Leader for the

Green Team submitted field trip request forms for the trip in accordance with Lewiston Public

School policies. The request forms identified the destination for the trip as Range Pond State

Park, and listed the number of anticipated students as 138, and the number of anticipated

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chaperones at 12. The field trip approval forms indicated that the trip would include “water

activities,” and identified the related “safety precautions” as “lifeguards.” Consistent with

Lewiston Public Schools policy, the field trip was approved by the Lewiston School Committee

on May 7, 2018.

In order to participate in the field trip, students were required to have permission slips

signed by their parent/guardian and returned to the school. The Green Team Field Trip

permission slip form disclosed the date, times, location and means of transportation for the field

trip. Rayan Issa returned a signed permission slip to the Lewiston Middle School before

participating in the June 12th field trip.

The portion of the permission slip form returned by parents and guardians stated that the

student ‘has my permission to attend a field trip to Range Pond State Park in Poland, Maine on

June 12, 2018, from approximately 8:45 a.m. to 1:45 p.m. (rain date June 20, 2018).” The form

also stated “I give permission for him/her to receive emergency medical treatment,” and

provided space for parents to provide emergency contact information and a space for the

parent/guardian signature. The reverse side of the form included certain “must bring items,”

including two bottles of water, a towel, sunscreen, and lunch for those who did not order a school

lunch. For “optional items,” the form listed a swimsuit, change of clothes, bug spray, beach toys

(balls, Frisbees, whiffle bat), inflatable devices, life jacket, and sunglasses. Finally, “things not

to bring” listed on the form included bats, hockey sticks, lacrosse sticks, and cellphones.

The team leader for the Green Team made an advance reservation for the field trip with

Range Pond State Park. The reservation included use of the picnic shelter at Range Pond. Upon

placement of the reservation, Range Pond State Park sent the Team Leader a confirmation notice

together with a set of rules for the State Park.

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 Of the approximately 138 students on the Green Team, 111 students participated in the

field trip after returning signed permission slips. The students were accompanied by 11 adult

chaperones, all of whom are employed by the Lewiston Public Schools, including a teacher who

serves as team leader of the Green Team, six teachers, a teaching coach and three educational

technicians. The ratio of adults to students was approximately 1 to 10, which was within the

ratio required by Lewiston School Committee Policy. Policy IJOA-R the Field Trip

Administrative Procedure, states that “[a]t least one teacher or other authorized adult must

accompany every…15 students at middle school level.”

After traveling by school bus from Lewiston Middle School to Range Pond State Park,

students and chaperones arrived at Range Pond at around 9:30 a.m. and met in the group shelter

area that had been reserved for the group. At that time, the Team Leader discussed ground rules

for students to observe. The rules shared with the students included listening to teachers, staff

and lifeguard, being safe in the water, staying within the roped off area, not venturing beyond the

lifeguard, and no horseplay in the water.

Range Pond State Park did not offer or provide a lifeguard or other State Park

representative to discuss safety rules with the group. When the Green Team visited Range Pond

State Park a year earlier in June, 2017, a representative from Range Pond State Park had met

with students upon arrival. Although media reports have indicated that a spokesperson for the

Maine Department of Agriculture Conservation and Forestry stated that the lifeguard on duty on

June 12th gave a standard safety talk to the group, the individuals interviewed during this

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investigation reported that the lifeguard did not give any safety or other talk to the group on June

12, 2018.1

After the Team Leader discussed ground rules with students, some chaperones went with

students to the changing area, and the LMS group then proceeded to the beach. At the beach,

there was one lifeguard, who initially was observed to be walking on the beach. After the

lifeguard went to the lifeguard stand, which was located toward one end of the beach, students

were allowed to go in the water. Chaperones arranged themselves in a row near the middle of

the beach, where they could observe students playing both in the water and on the beach.

Sometime after 11:00 a.m., a student, Student A called out for the Team Leader, who had

been at the water and had just returned to the area where the adult chaperones had placed their

chairs and blankets. In response, Chaperone A went to speak to the student. The student

reported to Chaperone A that he could not find Rayan, and the teacher attempted to determine

where Rayan had last been seen. This conversation was initially confusing to Chaperone A

because the student who reported Rayan missing did not appear to have a sense of urgency, and

some other students in the area began speculating that Rayan could be at the bathroom. Because

the teacher understood that the student could be in the water, however, she immediately went to

get the lifeguard at the lifeguard stand, while notifying other chaperones that Rayan was reported

to be missing. All chaperones on the beach went into action. The Team Leader went to the group

of students who Chaperone A had been speaking with, and got clarification from Student A that

he had last seen Rayan in the water. The Team Leader then went into the water and began

searching for the missing student. Another teacher, Chaperone B, who had just returned from the

bathroom, went back to the bathroom to see if he could find the missing student. Chaperone C,

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Brann & Isaacson has requested an opportunity to interview the lifeguard by contacting both Range
Pond State Park and the Maine Department of Agriculture Conservation and Forestry. To date, that
request has not been granted.

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another teacher, talked with two students on the beach with whom she had seen Rayan playing

earlier in the morning. When they reported that they did not know where he was, she asked them

to search at the bathroom.

When Chaperone A reached the lifeguard, she reported to him that a student was missing

and that he may be in the water. The lifeguard began looking for the student through his

binoculars, and Chaperone A asked him to come to the area where the student was last seen.

When Chaperone A and the lifeguard reached the area where the student was last seen, the Team

Leader already was in the water looking for the student. All students were instructed to get out

of the water, and students were instructed to line up by homeroom so that attendance could be

taken to confirm that the student was missing. After all students were accounted for, students

were instructed to return to the shelter area off of the beach. Some of the chaperones went to the

shelter area to supervise the students, and others stayed on the beach to assist in the search.

Following arrival of the lifeguard, the Team Leader called 911 and stayed on the line

with 911 until the first rescue unit arrived from the Town of Poland Fire Rescue. According to

the Team Leader’s cell phone records, it took nine minutes for first responders to arrive on the

scene. The Team Leader then called the School Principal to inform the Principal of the situation,

and then stayed on the line with the Principal and Assistant Principal to keep them informed of

the search and rescue efforts.

The perception of some employees at the scene was that the lifeguard initially did not

know what to do. One of the employees, Chaperone C, told the lifeguard that he should get in

the water to assist in locating the missing student. The lifeguard called for assistance from

another park employee on his walkie talkie, and asked for adult chaperones who could swim to

get in the water. The lifeguard then organized five adult chaperones to attempt a shallow water

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search to try to locate the missing student. The shallow water search technique involved the six

adults locking arms in a line and, while stepping forward in the water, sweeping their feet from

side to side with each step. Employees reported that while performing this technique, the water

got too deep to continue as there was a sudden drop off in depth that put the water over their

heads. At this time, the lifeguard instructed the participating adults to attempt a deep water

search by repeatedly diving into the deeper water in an attempt to locate the student. While some

of the chaperones found this difficult to perform, chaperones stayed in the water and continued to

search as best they could until rescue units arrived.

After arrival of the fire rescue personnel from the Poland Fire Department, rescue

officials asked to speak to students who had last seen the missing students in order to confirm the

location where the student was last seen. Three students were then brought to the beach where

they confirmed the area in which they had last seen Rayan. When rescue officials located the

missing student in the water, efforts were made to remove the three students from the beach as

quickly as possible. The student was placed into an ambulance and taken to the hospital. The

student was pronounced dead after arrival at the hospital.

EVALUATION OF FIELD TRIP PROCEDURES

The field trip to Range Pond State Park on June 12, 2018, was conducted in accordance

with existing Lewiston Public Schools policy. Authorization for the trip was properly requested

and approved by administrators and the School Committee. The ratio of students to adult

chaperones on the field trip was 10:1, which was within the 15:1 ratio for middle school students

specified in Lewiston Public Schools Policy.

Lewiston Public Schools does not have a policy that requires a minimum number of

lifeguards on swimming field trips. While there was an expectation that there would be more

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than one lifeguard on duty at Range Pond State Park, based on the experience that the same team

of teachers had the previous year, Lewiston Public Schools was relying upon Range Pond State

park to determine and provide appropriate lifeguard coverage.

There is not currently a Lewiston Public Schools policy that requires a specific

monitoring system or buddy system to be implemented on student field trips. While adult

chaperones were on the beach and monitoring students at the time of the incident, there was not a

buddy system in effect and there was not a system by which specific adults were assigned

responsibility for monitoring specific students or specific areas of the water. At the time that the

student was reported missing, there were six adult chaperones on the beach monitoring students,

including the Team Leader, and Chaperones A, B, C, D and E. One chaperone was returning

from the bathroom, two chaperones were supervising students at the shelter area, one chaperone

was supervising students at the playground, and one chaperone had left the beach area to take a

private phone call relating to a family member's medical condition.

Neither the adult chaperones nor the lifeguard observed the student in distress or

struggling in the water. Students who were playing football in the water with the student

reported seeing him go after the football into deep water and then struggling for a brief period of

time before he went under and did not come back up. Students who were in closest proximity to

Rayan estimated that the period of time that he was struggling in the water before going under to

be less than 30 seconds.

When the student was reported missing, adult chaperones responded appropriately based

on the information that they had. Chaperone A, the first chaperone to receive the report of a

missing student, went to get the lifeguard and simultaneously notified other chaperones that there

was a student missing. At that time, the Team Leader confirmed the student’s report that the

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student was last seen in the water, and the Team Leader went into the water to search for the

missing student. Because other students indicated that the student may have gone to the

bathroom, students and a chaperone went looking in other places to look for the student.

Upon arrival of the lifeguard, the Team Leader placed a call to 911, and adult chaperones

followed the instruction of the lifeguard in implementing both shallow water search and deep

water search techniques as instructed by the lifeguard. Chaperones gathered students on the

beach to take attendance, and then moved students off the beach while the search continued.

RECOMMENDATIONS

Lewiston Public School should adopt a policy that sets specific standards for field trips

involving water activities. Lewiston Public Schools continues to allow field trips that involve

swimming as an activity, Lewiston Public Schools should adopt a policy that establishes

minimum standards for approval and conduct of swimming field trips. A review of school board

policies adopted by other Maine school districts indicates that few, if any, Maine school districts

have specifically addressed water-related field trips in their school board policies. The standard

field trip policy IJOA published by Maine School Management Association, which many public

school districts in Maine use as a model starting point in drafting their own policies, does not

address water-related field trips.

Lewiston Public Schools currently applies a more stringent process for approval of water-

based field trips than many Maine school districts by requiring that field trips involving water

activities receive approval from the Lewiston School Committee.2 Because there currently are no

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LPS requires School Committee approval for any field trip involving water activities through
submission of an additional form for School Committee approval of any field trip that is overnight, out-
of-state, or involves either “water activities” or “watercraft-air transportation.” In this case, the Team
Leader who organized the June 12th field trip completed both forms, and the field trip received School
Committee approval as part of the School Committee’s consent agenda at the May 7, 2018 School
Committee meeting.

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written standards to govern the approval and conduct of water-related trips, however, there

should be standards to guide administrators and the School Committee in approval of such field

trips and to guide school staff in the conduct of such field trips.

Risk levels and best practices vary depending on the location, provider and nature of the

water activity. For purposes of making recommendations, this report divides recommendations

into field trips that involve swimming, field trips that take place near the water but at which

swimming is not allowed, and field trips that involve transportation on boats or other watercraft.

Swimming Activities

It is recommended that the policy and procedures adopted by the Lewiston Public School

for swimming field trips include the following minimum requirements:

1. Field trip participants should be required to demonstrate water competency before

being allowed to swim.

Students participating in swimming activities should be required to demonstrate water

competency and should be assigned to designated swimming areas based on their level of

competency. Boy Scouts of America Guide to Safe Scouting, at p. 6 (“All youth and adult

participants are designated as swimmers, beginners or nonswimmers based on swimming ability

confirmed by standardized BSA swim classification tests. Each group is assigned a specific

swimming are with depths consistent with those abilities.”); Swimming: Safety Activity

Checkpoints (Girl Scouts of America, rev. June 2016) (requiring that participants’ swimming

abilities be classified and clearly identified based on testing of swimming abilities).

Testing of water competency should be conducted by certified lifeguards who are trained

in the American Red Cross water competency sequence, which includes the following elements:

(a) Enter the water and completely submerge; (b) Rotate 360 degrees; (c) Level off and propel on

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the front or the back through the water for at least 25 yards; and (d) Exit from the water. Under a

two-tier system, participants who are able to demonstrate water competency should be identified

in some way, such as a specific wrist band, and allowed to swim in deeper water. Those who are

unable to successfully complete the water competency test should be required to remain in

shallower water (waist deep or less).

A three-tier system could also be used, which would identify participants as swimmers,

beginners or nonswimmers, with beginners passing a less stringent and shorter distance test than

swimmers. Under a three-tier system, each group would be identified through a specific color

wrist band or other method, with swimmers allowed into deeper water, beginners restricted to

swim in water no deeper than their necks, and nonswimmers restricted to no more than waist

deep water.

Implementation of this recommendation is likely to require that Lewiston Public Schools

arrange for its own properly certified lifeguards to perform the testing.

2. Ensure Adequate Lifeguard Coverage.

The Lewiston Public Schools should require that there is adequate lifeguard coverage at

facilities where students are allowed to swim. For the June 12 field trip, school employees relied

upon Range Pond State Park to provide adequate life guard coverage. Although Range Pond

State Park had two lifeguards on duty during the Green Team’s 2017 field trip, the State Park

had a single lifeguard on duty during the June 12, 2018 field trip.

Standards for minimum lifeguard coverage vary. Although Maine law does not set

standards for lifeguard coverage at public pools and beaches, rules adopted for public swimming

areas in some other states recommend a minimum of one lifeguard for every 25 swimmers in the

water. It is likely that the number of lifeguards on duty at Range Pond State Park on June 12 did

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not meet this standard, based on the size of the LMS group and the fact that there were other

members of the public swimming at Range Pond that day.

While most schools and other organizations rely on the operator of a public beach with

lifeguards to determine the appropriate lifeguard coverage, the June 12 incident suggests that

Lewiston Public Schools should ensure that there is a minimum level of lifeguard coverage for

any field trip in which students are allowed to swim. It is recommended that there be at least one

lifeguard on duty for every 25 individuals in the water. This ratio can be monitored and enforced

through a buddy system that requires swimmers to check in and out of the water as described

below. Because it likely is not possible to effectively ensure that this standard for minimum

lifeguard coverage is satisfied at swimming facilities open to the general public, where the

School Department has no control over the number of other swimmers who may be in the water,

the School Department likely will need to contract for its own certified lifeguards in order to

implement this recommendation.

3. Require monitoring of students through designation of “lookouts” or “watchers”

In addition to ensuring adequate lifeguard coverage, it also is recommended that one or

more adult chaperones be designated as “lookouts” or “watchers” to observe students in the

water and help to alert lifeguards if there are any issues. Both the Boy Scouts of America and

the Girl Scouts of America recommend designation of non-lifeguards to serve a lookout role

during swimming activities, in addition to ensuring a minimum level of lifeguard coverages. As

with lifeguards, an appropriate ratio for lookouts to swimmers would be 1 lookout for every 25

swimmers in the water. Ideally, lookouts would receive training in Basic Water Rescue, a 4-hour

training module offered by the American Red Cross, but this is not absolutely necessary if there

is adequate lifeguard coverage and an adequate number of lookouts.

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 4. Require monitoring of students through a buddy system.

It is recommended that a buddy system be used to monitor students during any field trip

that involves swimming activities. Under a buddy system, every participant is paired with

another. Buddies are instructed to stay together, monitor each other, and alert lifeguards and

monitors if either needs assistance or is missing. An effective buddy system in an aquatic

environment requires buddies to check into and out of the swimming area together. This can be

accomplished through use of a “buddy board” that is supervised by a staff member to keep track

of which students are in the water at any one time. Buddies are normally in the same ability

group and remain in their assigned area. If they are not in the same ability group, then they

would be required to remain in the area assigned to the buddy with the lesser ability.

Under a buddy system, periodic buddy checks should be implemented to remind

participants of their obligation to monitor their buddies and to determine how closely the buddies

are keeping track of each other. Every 5 or 10 minutes, or as needed to keep buddies together, a

designated adult should give an audible signal, such as a single whistle blast, and a call for

“Buddies.” Buddies are expected to raise each other’s hand within a specific amount of time,

and buddies who take longer to find each other are reminded of their responsibility for the

other’s safety. Once everyone has their buddy, a count is made by area and compared with the

total number known to be in the water. After the count is confirmed, a signal is given to resume

swimming.

5. Require a Safety Talk that covers the specific risks and hazards presented by the
swimming facility.

All field trips, including water-related field trips, should begin with a discussion with all

participants that covers the specific risks and hazards present at the facility. This safety talk

should include instruction from a lifeguard that is familiar with the facility. The safety

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discussion should include consideration of all conditions and hazards present at the facility,

including water depth, quality, temperature, and visibility.

Non-Swimming Activities Near Water

The Lewiston Public Schools may choose to conduct field trips in parks or beach areas

that are on the water, but at which students are not allowed to participate in swimming activities.

In water environments where swimming is not allowed, the following procedures should be

required:

1. Prohibit students from entering the water at all if there is no lifeguard coverage.

Students should not be allowed to touch the water, even at wading depth, if there is no

lifeguard coverage present. This ensures that students who may be nonswimmers are not exposed

to risk of drowning or other water accident without a certified lifeguard present.

2. Prohibit students from entering the water above their ankles if there is lifeguard

coverage.

On a non-swimming field trip, students should not be allowed to enter water deeper than

their ankles when there is a lifeguard present.

3. Require monitoring of students through a buddy system and assignment to designated

chaperones.

While students are near the water, extra vigilance should be required in monitoring of

students. Each chaperone should be responsible for monitoring the safety of an assigned group

of students, and a buddy system should be utilized. If students are allowed to enter the water up

to wading depth, they must first be authorized by their designated chaperone, and there should be

no more than __ students per chaperone touching the water at any time.

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 4. Require a Safety Talk that covers the specific risks and hazards presented by the

facility.

As noted above, all field trips, including water-related field trips, should begin with a

discussion with all participants that covers the specific risks and hazards present at the facility.

The safety discussion should include consideration of all conditions and hazards present at the

facility, and should cover the rules necessary to keep participants safe.

Boating Activities

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