A multiple-fatality outdoor education event in New Zealand in 2008 revealed that a 'systems approach' towards managing risks and training staff was widely considered to be normal and 'best practice'. This approach champions audit trails and economic efficiency, and one of its characteristics is the volume of paperwork required. One of the unacknowledged repercussions of this approach is a compartmentalisation of knowledge and responsibility. But best practice was not always like this. A Foucauldian discourse analysis was employed to understand how best practice has changed and what the roots of those changes were. Disconcertingly, the 'systems approach' continues to dominate outdoor education organisations, and the conditions that appeared to play a part in the tragedy of 2008 are still considered 'normal'.