DEVELOPING A SYSTEMS APPROACH TO RISK ASSESSMENT IN THE LED - PowerPoint PPT Presentation

BEYOND LIKELIHOOD AND CONSEQUENCE: DEVELOPING A SYSTEMS APPROACH TO RISK ASSESSMENT IN THE LED OUTDOOR ACTIVITY CONTEXT Clare Dallat

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) • “The failure to earlier undertake an appropriate, comprehensive risk assessment , proved critical”. (Worksafe Victoria, 2011)

ACTIVITY 1 CONDUCT A RISK ASSESSMENT FOR: • Five-day led outdoor education school program • Three group program • Activities are camping and rafting (expected Grade 2 water level) • The school is subcontracting the rafting component • Time of year that program will be conducted is late November in Eastern Victoria, Australia • Participants are year 9 novices – have never been rafting on a school program before

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THE SYSTEMS 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.

THE SYSTEMS APPROACH (RASMUSSEN, 1997 ) Changing political climate Public opinion Government and public awareness Real, invisible, safety boundary Regulators, Laws Associations Economic failure boundary Changing market Regulations Company conditions and financial pressure Adverse events Company Management Unacceptable Policy workload boundary Changing competency levels and education Plans Staff Boundary defined by official work practices Fast pace of Action technological change Work Hazardous process

KYLE VASSIL Government department decisions and actions Regulatory bodies and associations Camp manager did Camp manager did not Camp manager not Lack of training School culture School did not brief staff School did not instruct Lack of staff No emergency School camp Staff not not disclose require proof that aware of DEECD risk in water rescue of collegiate on how to supervise dam camp coordinator involved in risk management documentation trained in potential dam swimming was management for for supervisory decision activities or respond to about supervising assessments plan Local area government, inadequate water safety hazard to the ACA appropriately supervised swimming activities staff making emergencies swimming in dam Camp manager and schools and parents school not aware of Activity centre any previous incidents at the dam management planning Camp manager Camp manager did No communication Failure to conduct School did not School’s risk Camp scheduled Principal not aware of School did not inform School did provide Planning around not require schools to between school and did not provide a a risk assessment ascertain management and before swimming and budgeting DEECD safety parents of swimming risk assessment staff to student bring safety or rescue teachers regarding qualified on dam and swimming ability recreational assessments guidelines activity training for teachers ratio at camp equipment to the dam dam activity associated risks supervisor or experience swimming policy Camp coordinator did not seek Camp coordinator did not Camp coordinator was approval from understand need to seek parents for dam not aware of extent of approval from camp swimming activity duties manager to swim in dam Supervisory and Camp leader roles management decisions Camp coordinator and responsibilities Camp coordinator Camp coordinator lacked Camp coordinator did not ascertain were not well and actions students’ swimming did not communicate knowledge of camp was not aware of communicated leaders’ skills and risks associated with relevant DEECD capabilities Training and dam to parents abilities documents selection of camp leaders Camp coordinator’s Failure to provide coordination of advice to students Teachers initial Camp supervisory on what to do in coordinator’s Poor comms failure to take Staffs’ perception Camp coordinator’s Difficulty in responsibilities event of emergency between camp No emergency situation that students were poor knowledge conducting decision to leave coordinator management plan seriously trying to entice of dam area diving search young leaders in and teachers developed after event Poor them into the water systematically charge of search Failure to Camp leaders supervision of perceive search of the swimming student was wrong area Delay in activity Decisions and actions of in difficulty Staff’s lack of initiating Supervising camp Initiation of Student knowledge regarding search Uncertainty regarding leaders, participants and Poor coordination of coordinator and swimming inhales water students’ swimming whether student was search teachers leave dam activity and drowns other actors at the scene Students actually in water or not capabilities area inexperience of Student gets into Student becomes Camp leaders Student panics of the incident swimming in dam difficulty in the water submerged uncertainty regarding environments how search should proceed Inappropriate staff to student ratios for swimming activity Poor comms Removal of students Instruction of others Camp coordinator between camp and failure to use to leave dam area Delay in lack of knowledge coordinator and their knowledge of and search dialling 000 regarding other staff’s camp leaders situation elsewhere CPR qualifications Poor visibility in Cold water water Equipment, environment and meteorological conditions Lack of rescue Dam floor slushy Water depth Dam water dirty equipment and black

THE RESEARCH PROBLEM Inadequate risk assessment • frequently highlighted as a contributing factor in deaths and injuries of participants on led outdoor activities (LOA) The completion of a risk • assessment is a formal requirement in planning LOA’s The systems-thinking approach • to accident causation in LOA domain (and safety critical domains generally) is now prevalent The extent to which • schools/organisations consider and apply the systems approach to LOA’s when conducting risk assessments is not clear.

RESEARCH QUESTIONS 1. To what extent are risk assessment methods in both the LOA sector and other safety-critical domains, underpinned by systems theory? 2. What challenges and barriers exist for LOA practitioners in relation to risk assessments? 3. Can we integrate a systems thinking – based approach to risk assessment design and development? 4. Does a systems thinking-based risk assessment method achieve acceptable levels of reliability and validity?

PILOT STUDY 1 – HOW ARE LOA PROGRAMS CONDUCTING RISK ASSESSMENTS (RA’S)? RQ1: To what extent are risk assessment Government department decisions methods in both the LOA sector and and actions other safety-critical domains, Regulatory bodies and associations underpinned by a systems approach? Local area government, schools and parents Activity centre management planning and budgeting Supervisory and management decisions Student numbers and actions • 4 LOA RA’s analysed to Abrasions (1) Lost student (1) Limited skill (1) Medical conditions (3) Exhaustion (1) Special needs group (1) assess the extent to which High risk behaviour (1) Fractures (3) Infection (1) Dehydration (1) Burns (3) Fatigue (1) they were underpinned by Decisions and actions of leaders, participants and other actors at the contemporary systems scene of the incident Negative impact with Chafing (1) Abduction (1) Injury from arrow (1) Slips and trips (1) Strains and sprains (2) another group (1) thinking. Falls (3) Allergic reaction (3) Trailer reversing (1) Jumping (1) Diving (1) Falling objects (1) Sharks (1) Steep terrain (1) Sloping ground (1) Tree fall (1) Temperature hot/cold (3) Bike failure (1) Vehicles (1) Equipment, environment and • The ‘PEE’ approach meteorological Environment being harmed Communication device Road hazards (1) Weather conditions (2) Heights (1) Exposure (1) Jewellery (1) Unknown site (1) failure (1) conditions by human (1) Clothing entangled in bike Arts and crafts material Treed campsite (1) Wild animals (1) Water visibility (1) Drowning (3) Fire (1) Lightning (2) (1) (allergic reaction to) (1) Rips (2) Water quality (2) Sunburn (1) Exposed ridges/hollows (1) Cattle grids (1) Animal bites/stings (3) Trailer decoupling (1) Equipment failure (1)