Outdoors risk intensive workshop
By: Outdoors Victoria
This workshop will include:
• A briefing and discussion by Maritime Safety Victoria on their report into the Anglesea kayaking incident earlier this year. Go to Maritime Safety Victoria to download your copy of the report.
• Your first opportunity to discuss the new Australian Adventure Activity Standards following release of a consultation draft later this month. To subscribe to Australian AAS updates or view the consultation draft prior to the day go here
• Practical guidance on injury prevention by the wonderful UPLOADS team, details below:
What is the Learning from Real Incidents workshop?
This workshop aims to provide practical guidance on injury prevention in the delivery of led outdoor activity programs. Specifically, we wish to focus on specific incident cases to discuss and identify practical ways in which similar kinds of incidents can be prevented in future. The intention is to engage practitioners in a discussion about injury causation and prevention, and to support practitioners in translating the UPLOADS research in practice.
The National Trial Report
The UPLOADS team recently released the national trial report which provides an analysis of 12 months of Australian led outdoor activity incident and near miss data. Whilst this provides a summary of over 1000 diverse incidents, a key part of incident learning involves also focusing on specific cases to support injury prevention activities.
Incidents are much more than a number
They represent either real harm or, in the case of near misses, the potential that harm may have occurred. Behind each incident are people and stories, and by aiming to better understand the multiple factors and influences that contributed in some way to these incidents occurring, we can, as practitioners and researchers working together, make a real contribution to preventing reoccurrences.
A move away from the ‘blame culture’
Rather than progressing down the well-travelled road of blame or criticism aimed at the single person or people at the incident site, we will instead use case studies and incident investigation methods that start by posing the question, “Why did it make sense for the person or people to do that”? As a group, we will delve “up and out” to more fully understand and identify the contributory factors that help create the conditions for these real incidents to occur.
The workshop will begin by focusing on the tragic death of Kyle Vassil, a year seven student who lost his life while on a school camp in 2010. Following this, another five case studies from the UPLOADS dataset will be discussed. These include incidents related to the following activities: running/walking, campcraft, snow sports, wheel-sports (mountain biking), and river activities.
• How to apply systems theory to accidents in the outdoors
• Improved understanding of how to identify contributory factors to incidents
• A move away from the ‘blame culture’ towards an ‘up and out’ approach
• Understanding the importance of reporting rich information, and how to extract this detail
1.) Australian AAS core standards public consultation
The Australian Adventure Activity Standards (AAS) are a voluntary best-practice framework for safe and responsible planning and delivery of outdoor adventure activities with dependent participants.
The standards provide guidance on safety and other aspects of responsible activity delivery, such as respect for the environment, cultural heritage and other users. The standards are not a full legal compliance guide, nor are they a “how to” guide or field manual for outdoor activities. The standards do not provide guidance on providing a high-quality experience over and above safe and responsible delivery.
The first opportunity to discuss the new Australian Adventure Activity Standards following release of the consultation draft.
* Core Standards Your Say
* Australian Adventure Activity Standards, Part I : Core Standards – Public Consultation Draft [PDF]
TRANSLATING INTO PRACTICE (i)
Accidents involve more than just those at the immediate scene of the incident.
Second victims are practitioners involved in an incident that harms or kills others — or has the potential to do so — and for which they feel personally responsible;
❝ It is precisely the role of the contributor that fills second victims with guilt and remorse. It creates an insufferable tension with their professional mandate. … They were there to keep people out of harm’s way and to keep people safe. And their actions produced the opposite. ❞
— Dekker, S. (2013) “Second Victim: Error, Guilt, Trauma, and Resilience”
* Effectiveness of Safety Management Systems;
GOALS: Critical reflection skills for better understanding why systems fail and applying this understanding to safety management.
* Accidents: more than just people, equipment, environment.
More than ‘People, Equipment and Environment’… Adopting a Systems Approach to Accident Analysis and Prevention (Uploads Project, 2015)
❝ Safety science is one of the toughest games in town. Unlike the natural sciences, it is not enough for an idea to be read, quoted and tested. It has to work in practice as well. ❞
— (Reason, 2014)
* How organisations learn from failure and how they harness incidents to drive improvement remain some of the most pressing and fundamental questions in the field of risk and safety management.
(Macrae, 2014) Close Calls: Managing Risk and Resilience in Airline Flight Safety
The UPLOADS project is a major collaboration between the Australian led outdoor activity sector, the University of the Sunshine Coast, and Federation University. The ultimate aim is to better understand and prevent the injury incidents that occur during led outdoor activities.
• Human error is a symptom of problems across the system (it is a consequence not a cause)
• Incidents caused by multiple interacting factors
• To understand ‘failure’ look at why people’s actions made sense at the time
• Systems are unsafe
• Humans create safety through practices at all levels of the system
1.) Safety is impacted by the decisions and actions of everyone in the system not just front line workers.
2.) Near misses and adverse events are caused by multiple, interacting, contributing factors.
3.) Effective countermeasures focus on systemic changes rather than individuals.
The goal is not to assign blame to any individual, but to identify how factors across the system combine to create accidents and incidents.
ACCIDENT PREVENTION –> IMPROVE THE SYSTEM
Systems thinking & Accident analysis
• Hunting for the ‘broken component’ doesn’t work (Dekker, 2011. Drift into Failure: From Hunting Broken Components to Understanding Complex Systems)
• Need to go ‘Up & Out’ rather than ‘down & in’
• Countermeasures are more effective when they deal with systemic issues rather than individuals or components (Dekker, 2002 Reconstructing the human contribution to accidents: The new view of human error and performance; Reason, 1997. Managing the risks of organizational accidents summary)
• The factors influencing individual behaviour remain in the system
UPLOADS analysis tool.
Uses Rasmussen’s theory (virtual integration).
Rasmussen’s risk management framework (adapted from Rasmussen, 1997).
Accimap applied (i) Stockwell
22nd July 2005, Stockwell tune station, London, UK. Jean Charles de Menezes; misidentified as one of the fugitives involved in previous days failed bombing attempts.
* Jenkins, Daniel P., Salmon, Paul M., Stanton, Neville A. and Walker, Guy H. (2010) A systematic approach to accident analysis: A case study of the Stockwell shooting. Ergonomics, 53, (1), 1-17.
Accimap applied (ii) Kerang
Semi-trailer truck collided with V-Line passenger train 8402
“for reasons not determined the truck driver did not respond in an adequate time and manner to the level crossing warning devices”
* Salmon, PM, Read, GJM, Stanton, NA and Lenné, MG. (2013) ‘The crash at Kerang: Investigating systemic and psychological factors leading to unintentional non-compliance at rail level crossings’, Accident Analysis & Prevention, vol. 50, no. 0, pp. 1278-1288.
Multiple actors involved –> Actor Map
Accimap applied (iii) Mangatepopo Gorge Incident
Mangatepopo Gorge (NZ) tragedy in which six students and their teacher drowned while participating in a led gorge walking activity.
* Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP (2011) [Uploads Project]
* Salmon, PM., Cornelissen, M., Trotter, J. (2012) “Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP”. Safety Science 50(4):1158–1170 · April 2012
The role of human factors in led outdoor activity accidents
This report presents the findings derived from a review of the literature, the aim of which was to identify the Human Factors-related issues involved in accidents and incidents occurring in this area. In addition, to demonstrate the utility of systems-based, theoretically underpinned accident analysis methodologies for identifying the systemic and human contribution to accidents and incidents occurring in the led outdoor activity domain, three case-study accidents were analysed using two such approaches.
* Salmon, Paul, Williamson, Amy, Mitsopoulos-Rubens, Paraskeve (Eve), Rudin-Brown, Christina (Missy), & Lenne, Michael (2009) The role of human factors in led outdoor activity accidents: literature review and exploratory analysis. Monash University Accident Research Centre, Australia.
UPLOADS – contributing factors
The twelve-month report from the UPLOADS National Incident Dataset, which presents the data from the first 12 months of the national trial.
* The UPLOADS National Incident Dataset. The First Twelve Months: 1st June 2014 to 31st May 2015 (2016) [Uploads project]
MARINE SAFETY VICTORIA
Discussion by Maritime Safety Victoria on their report into the Anglesea kayaking incident earlier this year.
Maritime Safety Victoria, a branch of Transport Safety Victoria, has released its report into the rescue of eight kayakers and the loss of four kayaks off Anglesea in May.
* Safety regulator releases report on Anglesea kayak incident (2016-Aug-04) [Maritime Safety Victoria]
* Marine Safety Inquiry Report. Capsize and loss of kayaks off Anglesea. Tuesday 3 May 2016 (2016-Aug-03) Full report [Maritime Safety Victoria]
– increase in kayak fatal incidents
– increase in the number of kayak incidents
– Victoria highly represented in AUS/NZ figures
❝ Brauer Secondary College principal Jane Boyle said the lifesavers had only rescued two students.
“We chose to hold this activity at Anglesea front beach because lifesavers were present,” she said.
“This incident occurred early in the morning, well before [the bad] weather set in.
“Our staff monitored weather reports throughout the morning to ensure students were nowhere near the water by the time the weather changed,” she said. ❞
— Stranded at sea: the school camp from hell (2016-May-05) [The Age]
It is interesting to see how this apparent crisis management statement by the principal are contradicted by the MSV findings.
TRANSLATING INTO PRACTICE (ii)
UPLOADS First Key Issue Report: CAMPCRAFT
The first Key Issue Report: Campcraft. Campcraft-related injuries, near misses and illnesses emerged within the UPLOADS first 12-month dataset as frequently occurring incidents with potentially severe outcomes.
* UPLOADS First Key Issue Report: CAMPCRAFT (2016-may-17) [Uploads project]
* UPLOADS Key Issue Report: CAMPCRAFT. UPLOADS Twelve Months Campcraft Dataset: 1st June 2014 to 31st May 2015 [DOCX]
What does the data tell us?
1.) Based on analysis of the first 12 months of incident data reported through UPLOADS (see van Mulken et al, 2016), campcraft-related activities represent an important area of focus for injury prevention efforts in the Australian LOA sector.
2.) Campcraft-related incidents have various contributory factors related to the activity environment and equipment (e.g. cooking equipment, boiling water, fire), the activity leader (e.g. instructions provided), activity participants (e.g. experience and competence), supervisors/field managers (e.g. program design), and parents/carers (e.g. the communication of important dietary information.
3.) Whilst there are a series of targeted interventions that may provide a short term benefit, in the long term a network of countermeasures designed to enhance campcraft practice is required.
* All Burnt Out: Extinguishing Old Assumptions around Outdoor Cooking Clare Dallat (April 29, 2016) [Uploads Project]
– Behaviours around cooking; stove position, seating in front of stoves, etc.
– Risk assessments do not suitably cover cooking as an activity
Note: Trangias are a UK/AUS thing. USA/CAN staff wouldn’t have necessarily have encountered them. Don’t assume they know how to use them.
Kinglake (2010) drowning
Kyle Vassil, a year 7 student, drowned in a 3.7-metre-deep waterhole at the Alpine Ash Mountain Retreat at Toolangi, near Kinglake while on a school camp.
— Extract from Table 6. Other incidents IN Brookes, A. (2011). Research update 2010: Outdoor education fatalities in Australia. Australian Journal of Outdoor Education, 15 (1), 35 – 55 .
“There had been no substantive analysis undertaken by the school concerning swimming at this site, and little or no current advice had been passed on to the Year 7 homeroom teachers as a group”
“Central to all of this [all findings] was the failure of Aquinas School to undertake (or outsource) an appropriate assessment of the risk involved in the voluntary swimming activity in the dam”.
— Coroner Peter White, 2014 Victoria
“A STUDENT who drowned on a school camp called for help but his teachers hadn’t realised he was in trouble, a coroner has found.
Kyle Vassil, 12, drowned in a waterhole at Alpine Ash Mountain Retreat, Toolangi, on the first day of the camp in February 2010.
A teacher leapt in to try to save him, but it was two hours before his body was recovered.”.
— Shannon Deery (2014-Oct-27) Herald Sun
* White, P. (2014) Coroner: Inquest into the death of Kyle William Vassil (2014)
* Shannon Deery (2014-Oct-27) Teachers didn’t realise Kyle Vassil was drowning at school camp in Victoria, says coroner [Herald Sun]
RISK ASSESSMENT MODEL
* Clare Dallat, Paul M. Salmon, Natassia Goode (2015) All about the Teacher, the Rain and the Backpack: The Lack of a Systems Approach to Risk Assessment in School Outdoor Education Programs
Four school outdoor education risk assessments were analysed and Rasmussen’s (1997) Risk Management framework was used to map the hazards and actors identified in the risk assessments. The results showed that the hazards and actors identified reside across the lower levels of the Accimap framework, suggesting a primary focus on the immediate context of the delivery of the activity. In short, from a systems perspective, not all of the potential hazards were identified and assessed. This suggests that current risk assessment practice is not consistent with contemporary models of accident causation, and further, key risks could currently be overlooked. The need for the development of a systems theory based risk assessment process is discussed.
❝ The findings suggest that the risk assessment approaches within the four risk assessments may not be consistent with contemporary models of accident causation. The identified hazards and consequent risk assessment strategies were found to populate only the lower levels of the framework, with 76 of the 77 hazards identified focussing on the immediate context of the activity only. Further, the actors identified populated primarily across the immediate delivery context of the activity – those at the so-called ‘sharp-end’ were most commonly referred to within the risk assessment. The findings of this study undoubtedly reflect the risk assessment approach most commonly referred to within the domain’s literature on risk assessment – one that focuses almost exclusively on the immediate confines of the activity and specifically, on the “People, the Equipment, and the Environment”. ❞
❝ A second important finding is that the hazards identified at the lower levels are not consistent with the hazards
known to be prevalent in accidents in this domain. With only 17% of UPLOADS causal factor taxonomy being represented at the second level of the framework (Decisions and actions of leaders, participants and other actors at the scene of the incident), it seems evident that even in a level garnering significant attention in the risk assessments,
many hazards were in fact not being considered at all. ❞