BE YOND L IKE L IHOOD AND CONSE QUE NCE : DE VE L OPING A SYST E MS APPROACH T O RISK ASSE SSME NT IN T HE L E D OUT DOOR ACT IVIT Y CONT E XT Clar e Dallat
T HE CORONE R’S VE RDICT … • “I t wa s c le a r upo n the e vide nc e tha t the risk a sse ssme nt pro c e ss a pplie d [to the Be lls Pa ra de e xc ursio n] b y Mr Mc K e nzie a nd his sta ff wa s informa l, a d hoc a nd se riously ina de qua te ”. (Co ro ne r Ro d Cha ndle r, 2011 T a sma nia ). • “T he re ha d b e e n no substa ntive a na lysis unde rta ke n by the sc hool c o nc e rning swimming a t this site , a nd little or no c urre nt a dvic e ha d be e n pa sse d on to the Ye a r 7 ho me ro o m te a c he rs a s a g ro up”. (Co ro ne r Pe te r White , 2014 Vic to ria ) • “T he fa ilure to e a rlie r unde rta ke a n a ppropria te , c ompre he nsive risk a sse ssme nt , pro ve d c ritic a l”. (Wo rksa fe Vic to ria , 2011)
T HE RE SE ARCH PROBL E M • I na de q ua te risk a sse ssme nt fre q ue ntly hig hlig hte d a s a c o ntrib uting fa c to r in de a ths a nd injurie s o f pa rtic ipa nts o n le d o utdo o r a c tivitie s (L OA) • T he c o mple tio n o f a risk a sse ssme nt is a fo rma l re q uire me nt in pla nning L OA’ s • T he syste ms-thinking a ppro a c h to a c c ide nt c a usa tio n in L OA do ma in (a nd sa fe ty c ritic a l do ma ins g e ne ra lly) is no w pre va le nt • T he e xte nt to whic h sc ho o ls/ o rg a nisa tio ns c o nside r a nd a pply the syste ms a ppro a c h to L OA’ s whe n c o nduc ting risk a sse ssme nts is no t c le a r.
RE SE ARCH QUE ST IONS 1. T o wha t e xte nt a re risk a sse ssme nt me tho ds in b o th the L OA se c to r a nd o the r sa fe ty-c ritic a l do ma ins, unde rpinne d b y syste ms the o ry? 2. Wha t c ha lle ng e s a nd b a rrie rs e xist fo r L OA pra c titio ne rs in re la tio n to risk a sse ssme nts? 3. Ca n we inte g ra te a syste ms thinking –b a se d a ppro a c h to risk a sse ssme nt de sig n a nd de ve lo pme nt? 4. Do e s a syste ms thinking -b a se d risk a sse ssme nt me tho d a c hie ve a c c e pta b le le ve ls o f re lia b ility a nd va lidity?
SYST E MS T HINKING Real, invisible, safety boundary Economic failure boundary Adverse events Unacceptable workload boundary Boundary defined by official work practices
MANGAT E POPO GORGE T RAGE DY
PIL OT ST UDY 1 – HOW ARE L OA PROGRAMS CONDUCT ING RISK ASSE SSME NT S (RA’S)? RQ1: T o what e xte nt ar e r isk asse ssme nt Government department decisions and actions me tho ds in bo th the L OA se c to r and Regulatory bodies and o the r safe ty-c r itic al do mains, associations unde r pinne d by a syste ms appr o ac h? Local area government, schools and parents Activity centre management planning and budgeting Supervisory and management decisions Student numbers and actions • 4 L OA RA’ s a na lyse d to Abrasions (1) Lost student (1) Limited skill (1) Medical conditions (3) Exhaustion (1) Special needs group (1) a sse ss the e xte nt to whic h Fatigue (1) High risk behaviour (1) Fractures (3) Infection (1) Dehydration (1) Burns (3) Decisions and actions of the y we re unde rpinne d b y leaders, participants and other actors at the Negative impact with scene of the incident Chafing (1) Slips and trips (1) Strains and sprains (2) Abduction (1) Injury from arrow (1) c o nte mpo ra ry syste ms another group (1) thinking . Falls (3) Allergic reaction (3) Trailer reversing (1) Jumping (1) Diving (1) Temperature hot/cold (3) Falling objects (1) Sharks (1) Bike failure (1) Vehicles (1) Steep terrain (1) Sloping ground (1) Tree fall (1) Equipment, environment and meteorological Environment being harmed Communication device • T Road hazards (1) Weather conditions (2) Heights (1) Exposure (1) Jewellery (1) he ‘ PE E ’ a ppro a c h Unknown site (1) failure (1) conditions by human (1) Clothing entangled in bike Arts and crafts material Treed campsite (1) Wild animals (1) Lightning (2) Water visibility (1) Drowning (3) Fire (1) (1) (allergic reaction to) (1) Rips (2) Water quality (2) Sunburn (1) Trailer decoupling (1) Equipment failure (1) Exposed ridges/hollows (1) Cattle grids (1) Animal bites/stings (3)
ST UDY 2 - L OA PRACT IT IONE R SURVE Y (N=97) RQ1: T o what e xte nt RQ2: What me thods, ar e r isk asse ssme nt appr oac he s, F indings: me tho ds in bo th the c halle nge s and • Syste ms thinking -b a se d RA me tho ds a re no t L OA se c to r and o the r bar r ie r s e xist for L OA safe ty-c r itic al pr ac titione r s in b e ing use d in L OA do mains, r e lation to r isk unde r pinne d by a asse ssme nts? • Bra insto rming , prio r e xpe rie nc e & ‘ PE E ’ o ac h ? syste ms appr pro c e ss driving RA pro c e ss • I n g e ne ra l, a pic ture o f c o nfusio n a nd unc e rta inty in re la tio n to c o nduc ting risk a sse ssme nts, a s we ll a s a la c k o f po lic y g uida nc e a nd fo rma l tra ining , wa s o b se rve d. • Only a sma ll pro po rtio n o f the po te ntia l risks a ro und L OA pr ogr am de ve lopme nt, planning y a re c urre ntly b e ing ide ntifie d and de live r a nd a sse sse d. Da lla t, C., Go o d e , N., & Sa lmo n, P.M. (2017). “She ’ ll b e rig ht”. Or Will She ? Pra c titio ne r pe rspe c tive s o n risk a sse ssme nt fo r le d o utd o o r a c tivitie s in Austra lia . Jo urnal o f Adve nture E duc atio n and Outdo o r L e arning . DOI: 10.1080/ 14729679.2017.1377090
L OA RISK ASSE SSME NT Anglesea Kayaking Incident Accimap Figure 5 Accimap representing the LOA system level where the risks identified for assessment reside (adapted from Salmon et al, 2010) Request for review Absence of Government policy and of guidelines not mandate for budgeting followed up guidelines Government Departments Inadequate Regulatory bodies & compliance DET guidelines (Suitability for checking associations aquatic activities) requirement Regulatory Bodies and Associations Absence of formal training around DET guidelines Local area Hire company Principal and Strong cultural Government, Schools Activity risk assessment Out of date risk 10 year school council’s attachment to OE (surfing based, did not DET guidelines not assessment relationship with understanding and Activity centre parents and program at Brauer government Local area assess hazards related to worked through college of compliance management, planning wind strength) schools and budgeting Activity Centre Management, planning and Reliance on budgeting Technical & operational No formal Staff highly Supervising Use of Strong trust Activity Staff not fully experience for Pre-activity On water Emergency dynamic risk experienced staff not aware weather in group planning qualified dynamic risk meeting supervision rescue plan management assessment in activity of gale warning information ability assessment management decisions and Supervisory Kayakers Teachers Inability to make actions drift out of IRBs used to attempt headway and and sheltered retrieve kayakers Program (9%) rescue further capsizes Physical processes & Varying area actor activities levels of Selection of Initiation of Capsizing of 3 kayaks situated experience kayaking activity kayaks beyond the break across ‘teams’ participants Inability to IRBs used to Students Decisions and paddle Participants retrieve actors at the scene of the participants attempt actions of and other against high swim to reef participants from leaders, incident rescue winds reef Activity (40%) Group (10%) Staff (6%) “Participant, High wind equipment Equipment & speeds Two seater sit on top Two seater sit on top Availability of Reef in proximity (110Kms per kayaks (activity) kayaks (recovery) IRBs to activity meteorological surroundings environment” hour) environment Weather/ Equipment, (3%) Equipment conditions Venue (20%) Geography (4%) (9%) and
THE SYSTEMS APPROACH AND LOA RISK ASSESSMENT Real, invisible, safety boundary Economic failure boundary Adverse events Unacceptable workload boundary Boundary defined by official work practices
ST UDY 3 - RE VIE W OF T HE RISK ASSE SSME NT L IT E RAT URE RQ1: T o what e xte nt ar e r isk asse ssme nt me tho ds in bo th the Me thod: L OA se c to r and o the r safe ty- • N=342 c r itic al do mains, unde r pinne d by a syste ms appr o ac h? • Ra smusse n’ s (1997) se ve n te ne ts o f a c c ide nt c a usa tio n use d to e va lua te e xte nt to whic h me tho ds we re unde rpinne d b y syste ms a ppro a c h F indings: • Mo st RA me tho ds do no t use syste ms thinking -b a se d a ppro a c h. Ra the r, the y a do pt line a r, c ha in-o f e ve nt pe rspe c tive • Conc lusion – majority of risk asse ssme nt me thods are not aligne d with c urre nt unde rstanding of ac c ide nt c ausation Da lla t, C., Sa lmo n, P.M., & Go o de , N. (2017). Risky syste ms ve rsus Risky pe o ple : T o wha t e xte nt do risk a sse ssme nt me tho ds c o nside r the syste ms a ppro a c h to a c c ide nt c a usa tio n? A re vie w o f the lite ra ture . Safe ty Sc ie nc e . http:/ / dx.do i.o rg / 10.1016/ j.ssc i.2017.03.012
Recommend
More recommend
