KIDS OUTDOORS 2030...2. Near misses and adverse events are caused by multiple, interacting,...
Transcript of KIDS OUTDOORS 2030...2. Near misses and adverse events are caused by multiple, interacting,...
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Black Swan or Lame Duck?Risk Resolve
Clare Dallat
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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.
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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)
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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?
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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.
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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
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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
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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:
Clare Dallat
0428 306 009
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