KIDS OUTDOORS 2030...2. Near misses and adverse events are caused by multiple, interacting,...
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KIDS OUTDOORS 2030
KIDS OUTDOORS 2030...2. Near misses and adverse events are caused by multiple, interacting, contributing factors. 3. Effective countermeasures focus on systemic changes rather than
Black Swan or Lame Duck?Current Approaches to Risk Assessment within
the Led Outdoor Sector
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Aims:• Context of Risk Assessments in the LOA sector
• Dominant approach (“PEE”) vs. Systems Approach
• PhD Study: Development of a risk assessment process which is underpinned by contemporary systems thinking.
• Overview and results from two recent RA studies• Planned future studies
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Work Health and Safety Act 2011 (Queensland)
• …highest level of protection against harm to their health, safety and welfare from hazards and risks arising from work
• …to eliminate risks to health and safety, so far as is reasonably practicable….
• …proactive, and take all reasonably practicable measures…• …employers must consult with workers who are, or are likely
to be, directly affected by a matter relating to work health or safety…
• …workers contribute to the decision-making process relating to the matter.
Presenter
Presentation Notes
The principles of health and safety protection The importance of health and safety requires that employees, other persons at work and members of the public be given the highest level of protection against risks to their health and safety that is reasonably practicable in the circumstances. Persons who control or manage matters that give rise or may give rise to risks to health or safety are responsible for eliminating or reducing those risks so far as is reasonably practicable. Employers and self-employed persons should be proactive, and take all reasonably practicable measures, to ensure health and safety at workplaces and in the conduct of undertakings. Employers and employees should exchange information and ideas about risks to health and safety and measures that can be taken to eliminate or reduce those risks. Employees are entitled, and should be encouraged, to be represented in relation to health and safety issues.
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Hazards and risks?
• “A hazard is anything in the workplace that has the potential to harm people.
• A risk arises when it’s possible that a hazard will actually cause harm. The level of risk will depend on factors such as how often the job is done, the number of workers involved and how serious any injuries that result could be.”
(WorkSafe Victoria)
Presenter
Presentation Notes
According to WorkSafe Victoria… “A hazard is anything in the workplace that has the potential to harm people. A risk arises when it’s possible that a hazard will actually cause harm. The level of risk will depend on factors such as how often the job is done, the number of workers involved and how serious any injuries that result could be.” In the context of outdoor ed this means… Hazards: all potential elements of a program or trip should be considered as potential hazards (tasks, equipment, people, environment, documentation) Risk: estimate the likelihood and potential severity
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What does this mean for me?
Is it possible to meet our compliance obligations whilst at the same time, engaging in a meaningful process of hazard identification and risk assessment which actually prevents harm?
Presenter
Presentation Notes
What does this all mean for outdoor program design in practice… Risk identification and control….usually achieved through risk assessments…is required to meet your obligations under the OHS Act.
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The Coroner’s Verdict…• “It was clear upon the evidence that the risk
assessment process applied [to the Bells Parade excursion] by Mr Mc Kenzie and his staff was informal, ad hoc and seriously inadequate” (Coroner Rod Chandler, 2011 Tasmania).
• “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” (Coroner Peter White, 2014 Victoria)
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Coroners Findings Cont’d.
• “Central to all of this 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”.
• “The failure to earlier undertake an appropriate, comprehensive risk assessment, proved critical”. (Coroner Peter White, 2014 Victoria)
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Dominant model of Risk Assessment in the Outdoor Context
• The “People, Equipment and Environment” approach.
• Focuses predominantly at risks/actions at the immediate context of, and within, the confines of the activity.
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An alternative proposal: The Systems Thinking Approach
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.
Presenter
Presentation Notes
Well in the analysis of large scale organisational accidents and disasters, it is now widely accepted that the accidents which occur are caused by a range of interacting human and systemic factors (e.g. Reason 1990) – this understanding is described as the systems approach. The systems approach involves three core principles. Firstly, behaviour and safety is impacted by the decisions and actions of everyone in the system, not just frontline workers alone. This means that decisions and actions made by politicians, CEOs, managers, safety officers and work planners play a role in accidents, as well as frontline workers. This also means that safety is the shared responsibility of everybody working within the system. Second, near misses and adverse events are caused by multiple, interacting, contributing factors, not just a single bad decision or action. For example, a flawed decision made by a worker that led to an accident will likely have various upstream contributory factors-related to things like training, procedures, management, equipment, work scheduling. This means that human error should never be seen as the cause of an incident. Rather, we need to search for the reasons as to why that error occurred. It also means that the relationships between contributory factors are as important to take into account as the factors themselves. The third principles is that effective countermeasures focus on changes to the work system rather than on punishing or retraining individuals. This means that countermeasures should generally focus on policies, procedures and infrastructure rather than on punishment, warnings or retraining. While changes to training at times may be appropriate, we need to recognise that it is very difficult to change individual behaviour, especially if the system does not support changes in behaviour. For example, telling truck drivers not to speed or to take frequent brakes isn’t going to work if their supervisor tells them they need an urgent overnight delivery – the client, the money is always going to come first. Similarly, it’s also not enough just to change the procedures or the rules governing work and expect behaviour to change. Human perceive procedures as context-dependent – they are followed when the work conditions support their application. So we need to examine the factors that may potentially impact on the execution of procedures – such as staffing, management or equipment availability. Finally, the goal is not to assign blame. Rather, we want to identify how factors across the system combine to create injury causing incidents, so we can create better countermeasures. Now this might seem like an obvious question – why can’t hasn’t this understanding been translated into workplace contexts? In the following section, I’m going to describe a project where we’ve developing an incident reporting and learning system based on a systems approach to accident analysis.
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Adverse events
Real, invisible, safety boundary
Economic failure boundary
Unacceptable workload boundary
Boundary defined by official work practices
Systems thinking – Rasmussen’s RM Framework
Presenter
Presentation Notes
Basically, it says that work needs to occur within certain boundaries, to ensure that it is carried out safely. Sometimes, organisations can be working at the edge of these boundaries for a long time, without actually having an accident. It's only when something catastrophic occurs that they realise that they'd actually been in danger for a long time. The Kyle Vassil case is a good example of that - the school had been conducting the dam activity for a long time, without incident. This doesn't mean, however, that the activity was "safe". One of the key purposes of RA is to identify where a particular task is within the safety bubble - are you operating at the boundaries of safe practice, and what can you do to move out of the danger zone? actions and decisions across these levels interact with one another to shape behaviour, safety, and accidents.
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In short…
“There is no single cause. Neither for
failure, nor success. In order to push a well
defended system over the edge (or to make it
work safely), a large number of contributory
factors are necessary and only jointly
sufficient” (Dekker 2006: 80)
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Translating Systems Thinking into the Led Outdoor Context
• Within the led outdoor activity domain and within the broader field of safety science, it has been established that systems models are the most appropriate for understanding accidents and preventing future incidents.
• UPLOADS
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UPLOADS Accident Analysis Framework
State and Federal Government
Regulatory bodies and professional associations
Higher-level Management
Parents/CarersSchoolsLocal Area Government
Supervisor/Field Managers
Activity Leader
Activity Participants
Other People in Activity Group
Group Factors
Other People in Activity Environment
Activity Environment Activity Equipment and Resources
Presenter
Presentation Notes
UPLOADS Accident Analysis Framework/System approach is that you can use it as a guide for identifying the different types of hazards – basically it describes the entire “outdoor activity system” and therefore all the potential hazards that can exist within that system. The overall structure is reflects Rasmussen’s Risk Management framework, this framework is underpinned by the idea that systems comprise various levels; actions and decisions across these levels interact with one another to shape behaviour, safety, and accidents. As I mentioned before, we’ve adapted the levels to describe the led outdoor activity system. The causal factor taxonomy essentially consists of the causal factors are thought to play a role in incidents at each of these system levels. I’m going to start with the factors that appear closest to the initiation of the incident– First of all we’ve got the Activity Leader category, this category describes the decision and actions of the people instructing the activity e.g. Leaders, guides, instructors. It breaks down into 9 sub-categories, such as instruction, communication, judgement and decision-making, preparation and planning Then we’ve got the Activity Participants category: this category describes the people actively participating in the activity e.g. students, clients. It breaks down into 8 sub-categories. The we’ve got a category which describes the decisions and actions of Other People in Activity Group: this category describes the people in the activity group who are not participating in the activity but who contribute to the immediate supervision and provision of the activity e.g. Parents, teachers, drivers, cooks, cleaners. It breaks down into 9 sub-categories. Then we’ve got Group Factors: this category describes the dynamics within the group and factors impacting on group performance. It breaks down into 8 sub-categories. Then the last category at this level is Other People in Activity Environment: describes the people who are in the immediate activity environment but who are not part of the Activity Group e.g. members of the public, emergency services. It breaks down into 8 sub-categories. Below this level, we’ve got categories which describe: The immediate environment in which the activity takes place. It breaks down into 6 sub-categories. And the Equipment and Resources required to conduct the activity. It breaks down into 5 sub-categories. OK, so far we’ve described the decisions and actions of the people directly involved in the incident, the environment at the time of the incident and the equipment involved in the activity that was occuring at the time of the incident. Now we reach the systems factors. At the level directly above or outside the immediate context of the activity you’ve got Supervisor/Field Managers: describes the people who contribute to the planning/supervision of the activity and supervision of activity leaders. This category includes field managers, supervisors and administrative staff. It breaks down into 10 sub-categories. Their actions and decisions are regulated by the level above them – first of all by Higher-level Management: this category describes policies/procedures related to the provision of the activity, as well as the actions of Activity Centre Managers, Senior Managers and CEOs. It breaks down into 11 sub-categories. We then have Schools: describes the decisions/actions/policies/procedures/responsibilities of schools that have students involved in the activity. It breaks down into 6 sub-categories. And also Parents/Carers: describes the decisions/responsibilities of parents/carers who have children involved in the activity. It breaks down into 6 sub-categories. We then have the Local Area Government: describes the decisions/policies/procedures/responsibilities of the local area government where the activity takes place. This category describes factors such as poor maintence of camp grounds. At the level above this is the Regulatory bodies and professional associations: describes the decisions/policies/guidelines of regulatory bodies and professional associations relevant to outdoor activity provision, including education and training bodies that provide outdoor education/recreation qualifications (e.g. TAFE Cert. IV; Bachelor of Sport and Outdoor Education; Wilderness First Aid). It breaks down into 8 sub-categories. Finally, we have a category for factors relating to the State and Federal Government: the factor describes the decisions/policies/legislation of State and Federal government departments and bodies relating to the provision of outdoor activities. For example, National Parks and Wildlife Service; Sport and Recreation State Government departments; and Australian Sports Commission. It breaks down into 8 sub-categories. Overall, the taxonomy describes the incident context; the people directly involved in the incidents; and the people and agencies that indirectly impacted on the incident. You can use these codes as a guide for investigating incidents and for classifying the causal factors involved in incidents and the relationships between them.
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Risk Assessment using a Systems Approach
• Outcome: Hazards across the entire system would be identified, and consequent risks to participant (s) harm assessed and managed.
• PhD Study 1 & 2
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Study 1 – Systems Analysis of Risk Assessments
• Four outdoor education program risk assessments analysed to assess the extent to which they were underpinned by contemporary systems thinking.
• Accimap used to map hazards and Actors.
• 77 Hazards identified• 8 Actors • 3 States• Multiple activities (n=21)• Camp and Journey Based
Programs represented
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An Accimap displaying the identified hazards within the four risk assessments
Government department decisions
and actions
Regulatory bodies and associations
Local area government, schools and parents
Activity centre management planning
and budgeting
Supervisory and management decisions
and actions
Decisions and actions of leaders, participants
and other actors at the scene of the incident
Equipment, environment and
meteorological conditions
Student numbers
Medical conditions (3)
Burns (3)
Slips and trips (1)
Trailer reversing (1)
Chafing (1)
Jumping (1)
Limited skill (1)
Dehydration (1)
Strains and sprains (2)
Diving (1)
Exhaustion (1)
Fatigue (1)
Abduction (1)
Falls (3)
Special needs group (1)
High risk behaviour (1)
Injury from arrow (1)
Allergic reaction (3)
Abrasions (1)
Fractures (3)
Negative impact with another group (1)
Lost student (1)
Infection (1)
Sloping ground (1)
Environment being harmed by human (1)
Wild animals (1)
Exposed ridges/hollows (1)
Treed campsite (1)
Cattle grids (1)
Steep terrain (1)
Unknown site (1)
Lightning (2)
Animal bites/stings (3)
Tree fall (1)
Road hazards (1)
Water visibility (1)
Rips (2)
Temperature hot/cold (3)
Weather conditions (2)
Drowning (3)
Water quality (2)
Falling objects (1)
Heights (1)
Fire (1)
Sharks (1)
Exposure (1)
Sunburn (1)
Clothing entangled in bike (1)
Bike failure (1)
Communication device failure (1)
Trailer decoupling (1)
Arts and crafts material (allergic reaction to) (1)
Vehicles (1)
Jewellery (1)
Equipment failure (1)
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An ActorMap displaying the identified Actors within the four risk assessments
Government Policy and Budgeting
Regulatory Bodies and Associations
Local area government, parents, schools and
activity centre management, planning
and budgeting
Technical and operational management
Physical processes and instructor/participant
activities
Equipment and surroundings Equipment Physical
Environment
InstructorRisk Assessments
1, 2&4
ParticipantsRisk
Assessments 1,2,3&4
Group
Supervisors
Managers (e.g. programs, training,
risk, teaching)Risk Assessment 1
Activity Centre senior
management/board level
Local Govt and councils
Risk Assessment 2
Schools, school principals and
school councils
Regulatory bodies
ParentsRisk
Assessment 2
Government bodies
State Departments of Education e.g.DEECD
State Departments of Land
Management e.g. Parks Victoria
Accreditation bodies Auditing bodies
Peak bodies for outdoor recreation, outdoor education,
and adventure tourism
State Adventure Activity Standards
Standards Australia
Outdoor Council of Australia e.g. National outdoor
leaders reg scheme
Emergency services
Meteorological conditions
Ambient conditions
TeachersRisk
Assessments 1,2,&3
LifeguardRisk
Assessment 2
Support driverRisk
Assessment 3
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Study 2 – Industry Survey • Online and voluntary
• Aim:• 1) enable a greater understanding
of how risk assessments are currently being conducted and;
• 2) identify desired improvements in risk assessment tools.
• Total sample (n=97)
• All states and territories represented in findings
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Initial FindingsGender Split
• Male – 76%
• Female – 24%
Type of Organisation
• OE Provider – 55%
• School – 30%
• RTO – 17%
Experience (Years)
• 0-1 – 11%
• 2-3 – 24%
• 4-5 – 14%
• 6-10 – 16%
• 10+ – 35%
How useful are risk assessments in preventing harm on outdoor activities? (1-10)
• 91% rated 5 or higher
Do you experience confusion in risk assessments?
• Yes – 52%
• No – 48%
Do you believe there are any issues regarding the application of risk assessments to the outdoor activity/program context?
• Yes – 79%
• No – 21%
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Findings Cont’d.Do you complete risk assessments as part of your role?• Yes – 77%• No – 23%
Where did you first learn to complete a risk assessment?• On the Job – 52%• University Course – 25%• TAFE Course – 17%• Other – 6%
Are staff provided with a copy of the risk assessment?• Yes – 74%*• No – 26%*Mostly as a one-off at training/induction
Are parents provided with a copy of the risk assessment?• Yes – 21%• No – 79%
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Challenges with RA’s• “Time poor organisers completing RA's
properly”.
• “Sometimes it is difficult to draw a line on where to stop assessing risk”.
• “Instructor knowledge and awareness gaps”.
• “It's the individual staff that can become the problem if they don't follow the RA or if the organisation does not check that staff understand their RA”.
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Challenges Continued…• “If something still goes wrong, there
needs to be someone to blame, and the people responsible for approving the process will never take the blame”.
• “Complexity and actual applicationduring program”
• “Risk assessments can be an issue if they begin to impinge on the common-sense approach to conducting an activity”.
• “Hesitancy to share sources/documents within the community (often due to perception that they will be showed up/identified as doing something wrong)”.
• “Lack of a safety culture established within management. A risk assessment is seen as a stand alone risk management document (the be all & and end all)”.
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More Questions… “To what degree do you go?...
you could for example provide a risk assessment for every stinging insect you may encounter”.
“They can be copied from year to year without any thought”.
“Inexperienced leaders implementing a risk assessment they have limited knowledge about”.
“Relies on our past experiences which may not include all possibilities”.
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Where To From Here?• Design, validation and piloting of a risk assessment
tool which adopts a systems based approach. Will require industry/school involvement (end of 2015 –2016)
• Questions/ Comments/ Thoughts?
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Thank you!For more details on how to get involved:
