UPLOADS National Dataset Website Scoping Survey Results

Recently, the UPLOADS Research Team conducted a survey to determine whether we should develop a website that allows people within the outdoor education, recreation and adventure sector to access and explore the findings from the National Dataset.

Results at a glance:

  1. 35 people responded to the survey.
  2. All participants thought such a website would be a useful resource, and almost all stated they would use it.
  3. Top three uses for the website: Develop risk management and control strategies (94%); look at summaries of incident data (86%); and understanding the causal factors involved in incidents (77%).
  4. Top three desirable features: Basic search functions (search by activity type, type of incident, type of adverse outcome) (94%); Incident data displayed in the context of relevant participation data (80%); and Printable summary reports (77%).
  5. Risk controls: 74% of participants thought they were sufficient, 23% were unsure and 3% said they were not.
  6. An increased sample size and controlled access to the website were suggested as potential additional risk controls.

The results indicate that there is support from the sector. Therefore, funding will be sought to develop and pilot the proposed website. The ideas and insights gained from this survey will be used to inform the development of the website.

Click here to read the results in full.

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Posted in Outputs, UPLOADS

Beyond the leader, the rain and the harness… assessing risk in the outdoors

by Clare Dallat, PhD Student (Human Factors), University of the Sunshine Coast Accident Research Centre

This video was recorded at a presentation by Clare Dallat and Natassia Goode at Hillbrook Anglican School.

Over the past decade risk assessments have become a non-negotiable part of outdoor programs. This is partly driven by WHS Legislation and increasing interest in organized outdoor activities from regulatory authorities, but also by a realization within the sector that a proactive approach to hazard identification and risk management is required to prevent serious injuries. Despite this, confusion remains at the planning and practice level regarding the most appropriate process to take. How can we ensure risk assessments are meaningful and not simply futile compliance exercises in ‘ticking the box’?

As a practitioner for the past twelve years in a risk management role I have experienced significant challenges around risk assessment. I have seen first-hand our adversarial legal system through expert witness and defendant duties and interacted with WHS inspectors. I’ve also worked regularly with schools and organization’s conducting outdoor excursions throughout Australia. Based on my experiences, the following questions seem critical:

  • Is it possible or practical to engage all program participants in risk assessment, including students, parents and staff?
  • Where do we start and stop in relation to hazards and risks?
  • What if an incident happens and I hadn’t identified that it could have occurred in the first place?
  • How do we enable staff to discuss hazards and implement the risk controls that are likely to reduce the potential for harm and injury on programs?
  • How do I know if what I’m doing is ok?
  • How do we achieve both compliance with relevant legislation and societal expectations and empower our staff to make decisions based on what is occurring around them? Are both possible?
  • How do we move from a fear-based approach (e.g. “What will a court say”? or “There’s no way I can send this risk assessment to a parent because they wouldn’t send their child if they saw it!”), to one of collaboration, where the aims of the program and the resulting hazard management processes are both successful and where compliance has been achieved?

The ‘Systems Thinking’ Approach

Exploring a ’systems thinking’ approach may provide answers to some of these questions.  Fortunately for me, the opportunity has arisen to embark on a full-time PhD with Natassia Goode and Paul Salmon at the University of the Sunshine Coast Accident Research Centre (USCAR) to explore these challenges further.

It is now widely accepted that incidents are caused by multiple interacting factors across the overall system of work. This means that an incident reflects a systems problem and there is no such thing as a root cause. Accidents aren’t caused by individuals, they are caused by systems.

If, for example, we were to apply this ‘systems thinking’ approach to risk assessments in our own sector, additional layers outside the commonly focussed upon categories of ‘people’, ‘equipment’ and ‘environment’, would be viewed as providing potential causal factors and therefore in need of consideration.  These additional layers, for example, would include:  the role of the overall risk management processes and procedures, supervisors and wider organizational factors, parents, schools, Adventure Activity Standards (AAS), CARA/DEECD/DET guidelines etc., and VET and University training programs (that train future staff in risk assessment). A systems thinking approach would consider the potential risks at all of these levels, and importantly how they might interact together to create accidents.

Interestingly, this lack of systems thinking in risk assessment is not limited to the outdoor sector. The literature across other safety critical domains (e.g. aviation, healthcare, transportation) is not populated with significantly alternative approaches to risk assessment than what we find in our own domain. The inescapable conclusion is that risk assessment processes have not kept pace with what we know about accident causation. In short we are not assessing all of the risks present within our systems – we are just scraping the surface.

Across many domains, there continues to be a substantial focus on the work performance and hazards at the ‘sharp end’ – the people directly involved with the task. Within our own sector, this is generally the instructors and staff directly in front of participants, the environmental conditions and the equipment used.  Whilst these elements are obviously vital in the overall program, there are, as we now know, multiple other contributing layers and ‘actors’ in the system which require consideration in any risk assessment process.

The aim of this PhD project is to design, develop and trial an alternative systems approach to risk assessment for application in the outdoor sector; the project having, as its ultimate intention, the reduction of injury-causing incidents to participants and staff on such programs.

Over the next few years, we will be looking for schools and organization’s to collaborate with us and assist in the development of the project. If you, or your organization is able to be involved, please contact me directly at Clare.Dallat@research.usc.edu.au or 0428 306 009.

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Posted in Events, Risk assessment

Risk Assessment Process Workshop

Over the past five to ten years risk assessments have become a non-negotiable part of outdoor programs. This is partly driven by WHS Legislation and increasing interest in outdoor education from regulatory authorities, but also by a realisation from within the sector that a proactive approach to hazard identification and risk management is required to prevent serious injuries. Yet at the planning and practice level confusion remains as to how to approach this process in a meaningful way and not simply just a futile compliance exercise in ‘ticking the box’.

As a practitioner and risk manager for many years, Clare Dallat has witnessed this challenge and has initiated strategies within both her own organisation and those that she consults with regularly; to attempt to empower staff at all levels more in relation to risk assessment. This interest has now led to a full-time PhD with the Accident Research Team at the University of the Sunshine Coast (USCAR) to develop a risk assessment tool for organised outdoor activities that adopt a ‘systems thinking’ approach.

In this workshop, Clare and I will discuss approaches and methods for conducting risk assessments that: 1) Address compliance requirements; and 2) attempt to focus on meaningful outcomes that align and compliment the desired aims of the program. Socio-technical systems theory will be discussed as a potential underpinning framework that can drive a more holistic and collaborative approach to risk assessments.

We will aim to show that conducting a good risk assessment should not be a futile exercise; rather, that it can and should be an empowering, conscious and collaborative process of identifying and taking action to minimise the potential of serious injury or harm to participants and staff on your programs.

So come along and have your input into the actual development of a risk assessment process that aims to both comply with legislation, as well as being a successful tool for minimising harm and leading to the achievement of the fantastic desired aims of your programs.

When: 5pm, 11th November, 2014

Where: Hillbrook Anglican School

Follow the link below to sign up.

http ://qorf . org . au/whats-on/risk-management-workshop/

or contact the OEAQ office for more details – 5484 5433 or oeaq@oeaq.org.au

Thank you to OEAQ for organising!

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Posted in Events, OEAQ, Risk assessment

Have your say: a website to explore the UPLOADS National Dataset?

Invitation to people working in the outdoor education, recreation and adventure sector: UPLOADS website scoping study (Ethics Number: A/14/604)

One of the goals of the UPLOADS Project is to develop a National dataset of incident reports and participation data so that the led outdoor activity sector can understand the risks it faces and take appropriate action.

The UPLOADS Research Team are considering developing a website that allows people within the outdoor education, recreation and adventure sector to access and explore the findings from the National dataset, enabling them to understand injury and accident trends across the Australian led outdoor sector and different led outdoor activities. The website would allow people to search for certain types of incidents (e.g. all high ropes incidents involving injuries) and generate summaries of the data which, for example, would show the causal factors involved across the set of incidents (e.g. in 23 out of 30 high ropes incidents across Australia equipment and risk assessment were identified as causal factors). In addition, the website could be used to identify strong relationships between causal factors (e.g. in 70% of led outdoor activity incidents there is a strong relationship between financial pressures and inadequate training programs).

To ensure confidentiality, the website would only present summaries of multiple incidents from multiple organisations. Individual reports or details on specific incidents would not be accessible. The report on the prototype trial is an example of the type of information that would be presented (https://uploadsproject.org/wp-content/uploads/2014/05/goode-et-al-2014-summary-of-uploads-prototype-trial-results-18th-march-2014.pdf)

The aim of this study is to: 1) Evaluate whether the control measures we have in place to ensure confidentiality are considered sufficient for the website; 2) Determine whether people within the outdoor sector would use the website; and 3) Identify desirable features.

Your contribution to this study will allow us to determine whether we should develop the website and, if so, the essential features it needs to include.

The survey will take no more than 20 minutes to complete.

If you work in the outdoor education, recreation or adventure sector, and would like to add your valuable contribution please complete the survey here:

https://www.surveymonkey.com/s/uploadswebsite

Thank you

The UPLOADS Project team

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Posted in Invitations to participate in research

UPLOADS October Newsletter

Click here to read the UPLOADS Project October Newsletter which includes an invitation to participate in a survey on how we should use data from the National Dataset.

Posted in Uncategorized

The seductive logic of the search for the “root cause”

A recent article by Nancy Leveson and Sidney Dekker discusses the problems associated with searching for the “root cause” of accidents.

The article argues that trying to identify, and eliminate, the “root cause” of accidents leads us to focus on symptoms, rather than the underlying causes of accidents.   For example, in the outdoor context the symptom might be “participants doing the wrong thing”, while the underlying causes might be unclear instructions, design of the activity, and communication with the school about behavioural problems.

There’s also a good discussion of the common biases associated with understanding accidents, and how a systems thinking approach (like UPLOADS) can help overcome these biases.

The article was written for the Chemical Processing industry, but is useful for anyone interested in learning more from accidents.

Click here to read the full article.

Posted in Systems thinking, UPLOADS

Its good to talk – does your system?

In my last post I spoke about the dangers of focusing on a single root cause when investigating accidents.

However, while there is no doubt that accidents are caused by multiple contributing factors, one key element does continue to rear its ugly head in our research. This element is common across accidents, as well as across different types of causal factors in the same accident.

So what is this ubiquitous contributory factor?

Communication. In most accidents, there are often numerous communications issues or failures across all levels of the work system.

Critically, communication issues often occur within and across levels of the system. Within levels, for example, these issues are often evident when participants do not understand or misinterpret instructions from activity leaders. Across levels, field managers might provide overly complex instructions about risks and hazards to activity leaders. Inexperienced activity leaders might not ask their field manager the right questions about what to do in an emergency. Parents might misinterpret the questions on consent forms, or misunderstand the risks communicated about the activity. Schools might fail to communicate with the activity centre about behavioural issues. Communications issue are often present at the highest levels of the system; for example when government and regulatory bodies are not on the same page.

Importantly, it’s not only about people not talking to one another or telling each other the wrong thing; often it is poor communication within documentation, policy and procedures, training programs, risk management and incident reporting systems, and equipment. For example, an incident reporting system might contain information about recurring hazards. However, for whatever reason this information in not communicated to the people who need this information most. The end result is a system that is not aware of its own hazards.

So whilst the contributory factors themselves may be different in terms of their source, often they centre on safety-critical communication. Communication, it seems, has a lot to answer for when disaster strikes.

The important messages here are that it is it is good (for every ‘thing’ in the system) to talk (about everything that is important) to the right people: it is important to make sure that your system “talks”. Make sure you have processes in place that allow all the people within your system (participants, leaders, field managers, risk managers, admin staff, parents etc.) to talk about the important issues, to communicate the right information to the right people, and to monitor understanding. It’s not enough just to “send” the information, you have to know it has been heard.

Let’s repeat that. It is good for everything in the system to talk about everything that is important to the right people. Sounds simple doesn’t it? Unfortunately it is often not achieved across the safety critical domains, as evidenced by recent tragic events in other areas. The Air France 447 tragedy in which an Airbus A330 dropped into the Atlantic Ocean killing all on-board effectively happened because the aeroplanes systems couldn’t communicate with one another, the cockpit displays couldn’t tell the pilots what was going on, and the aircrew didn’t communicate particularly well about what they were doing in response to the situation. The Kerang rail level crossing tragedy of 2007 happened because the rail level crossing did not effectively communicate to the truck driver that a train was approaching. Moreover, the hazards around the crossing were not effectively communicated across the system.

How should organisations deal with this? The wrong approach is to send a memo around your organisation telling people to talk more often to one another. This will fix nothing much really, other than people might be chattier over lunch for a week or so. But it’s not safety critical information and remember it’s not just people that are the problem – it is ‘things’ too. The right approach instead is to work out what needs to be communicated to ensure safety, who needs to know it, and what or whom should be communicating the information. Only then can you identify where these ‘communication’ issues exist and fix them. Revise the policies, risk management programs, procedures, increase the communications channels, incorporate regular reporting into incident reporting systems etc. Get the system talking. It might just be the fundamental change it needs to supercharge safety.

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Posted in Systems thinking

PhD Scholarship news!

The University of the Sunshine Coast Accident Research (USCAR) Team is offering two new PhD scholarships.

One of the scholarships available involves using the data from the UPLOADS national incident database as a starting point for developing methods to improve safety management in the outdoors. Areas of interest include accident analysis/prediction/prevention, incident investigation and near miss reporting processes.

The successful candidates will join USCAR’s team of Human Factors researchers and will be located at the University of the Sunshine Coast in Queensland. The scholarships are advertised for an immediate start.

The application deadline is the 24th October – so if you’re interested you need to act quickly!

Click here for more details

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Posted in Uncategorized

Systems thinking 101..the root cause of accidents and some unanswered questions

What is the most common “root cause” of accidents? That’s the question I’m most often asked as an accident researcher, regardless of project, stakeholder, organisation, or domain.

No doubt the intention is good. The organisation wants to expend its limited resources in the most efficient manner. It can’t afford to solve everything, so its efforts would be best suited if focussed on the one thing that’s involved in all incidents. Unfortunately this way of thinking is dangerous for many reasons. 

First and foremost there is never one specific contributory factor responsible for an accident. There is no root cause. Accidents are a complex phenomenon. They are caused by multiple interacting factors across the overall system of work, and often even normal, commonly accepted behaviours play a role in the ultimate outcome of events. Root cause thinking is too simple for such a complex beast – it ignores the many factors that contribute to accidents.

This means that it would be dangerous for organisations to think that there was one thing, one silver bullet, which they can focus on when developing accident countermeasures.

For example, imagine a series of incidents involving equipment failures. The organisation, with all good intentions, gets rid of their tired and broken equipment and goes out and acquires the latest state of the art equipment. A significant expenditure, no doubt, and one that would improve the quality of resources available to their workers.

The big problem, of course, is that they have not addressed why their equipment was tired and broken in the first place. The competing financial pressures, the limited allocation of funding for equipment maintenance, that ancient policy around replacing equipment, those equipment maintenance procedures, the absence of lines of communication around broken equipment, the training that doesn’t cover inappropriate usage of equipment etc. They are all left free to continue influencing events, to wreak havoc on the new shiny equipment; which in turn means this equipment will eventually return, gently pushed along by these other factors, to the unsafe state. The equipment alone was a red herring. In systems thinking terms replacing the equipment only would be a waste of time – little would change in the long term.

There is no root cause – avoid the temptation to think that there is and to focus on finding and removing it. This leaves many pertinent questions: how can we develop countermeasures that fully address the system wide factors that contribute to failures? How can we avoid the temptation to focus on root causes? How can we stop trying to eliminate the components of failure one by one, and instead identify effective, holistic, solutions? These remain key questions, not only for practitioners, but for researchers as well.

In our work with UPLOADS, and our projects in road and rail transport, we are trying to come up with some creative methods to address this problem. Stay tuned…

 

 

 

Posted in Uncategorized

UPLOADS Project Newsletter August 2014

Click here to read the UPLOADS Project August Newsletter which includes a participation update and information on our latest publications.

Posted in Newsletter
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