Understanding Accidents

Understanding Accidents in the Great Outdoors

The Human Factors Approach

Led outdoor activities are an integral part of young Australians’ development, health and physical education. Despite their popularity, recent high-profile accidents, such as the drowning of a 12-year-old student during a college camp, pose a serious threat to the industry.

Injury-causing accidents will continue to occur during led outdoor activities.

Preventing or mitigating them requires initiatives such as collecting and analysing accident data. With factors and trends identified, countermeasures can then be developed. Recent research has found that the Australian led outdoor industry’s understanding of accidents is limited, which is down, in part, to the absence of a standardised accident and injury surveillance system. This makes it difficult, if not impossible, for the industry to prevent accidents and reduce risk effectively.

In response, the industry is working with academia to develop, trial, and implement an accident and injury surveillance system designed to increase knowledge on led outdoor activity accidents. The system will include accident reporting, data storage, and analysis methods and will enable the industry to collect accident data and analyse it in a systematic way, with the results helping develop accident countermeasures. A key part of the surveillance system is the way accident reports are analysed and a popular accident-analysis method already in use elsewhere could easily lead to a better understanding of accidents and their causes.

Understanding And Preventing Accidents: A Systems Approach

Accidents are complex situations. Causal factors reside at all levels of the ‘system’ in which the accident occurs, and they interact with one another in a way that influences human performance. The ‘system’ includes everybody involved – not just front-line workers but also any regulatory bodies, policies and procedures, managers and supervisors, equipment, the environment and so on. This is known as the ‘systems approach’ and in recent times it has driven successful accident analysis and prevention activities in many areas.

Accidents’ causes can lie dormant for weeks, months, even years, until eventually they interact with one another in a way that produces failure. They are difficult to identify, and the possible interactions between them are hard to predict. As a result, outdoor education suppliers often operate blissfully unaware that they are drifting towards catastrophe. The importance of collecting and understanding all accident and incident data is therefore paramount; when accidents happen, organisations need to learn as much as is possible from them. This is as true for small incidents and near misses as it is for large and catastrophic accidents.

Various accident-analysis methods are underpinned by this philosophy. Recent research suggests that one such approach, Accimap, is highly suited to investigating led outdoor activity accidents and in helping develop appropriate countermeasures. Accimap is used to identify the causal factors involved in accidents across multiple systems levels: government policy and budgeting; regulatory bodies and associations; local-area government planning and budgeting (including company management, technical and operational management); physical processes and actor activities; and equipment and surroundings. The factors identified are then linked between and across levels based on cause–effect relations. For led outdoor activity accidents, this means we can see contributing factors across the entire spectrum of participants, from the environment in which the activity takes place to the participants and instructors, their equipment, the activity centre providing the activity, and the regulations around activity centres.

By way of demonstration, an Accimap analysis of the Mangatepopo Gorge walking tragedy is presented below.

Accimap Mangetepopo Gorge

The incident occurred on the 15 April 2008, when a group of ten college students, their teacher and an instructor were caught in a flash flood whilst walking in the Mangatepopo Gorge in the Tongariro National Park, New Zealand. Tragically, six students and their teacher drowned. In the aftermath, the coroner and an investigation identified various contributory factors across the led outdoor activity system.

The Accimap presented is based on a report describing the findings from an independent inquiry into the incident initiated by the activity centre involved. The Accimap below is based on the findings of this inquiry and the contents of the report.

The Accimap shows how decisions, actions and failures across the entire system interacted to enable the tragedy to occur. Importantly, it shows how failures from other levels of the systems – including legislation and regulation, activity centre operation, instructor supervision, equipment and environmental conditions – influenced the instructor’s behaviour and decision-making during the incident. Thus, rather than blame explicitly the part played by the instructor, the analysis instead supports an appropriate systems reform.

Failures across the entire system clearly played a role. Starting at the bottom of the Accimap, examples of ‘equipment and surroundings’ factors include the adverse weather and conditions in the gorge, an incomplete weather report used in the morning staff meeting, and the radio used by the instructor (which was not waterproof and failed to work in the gorge due to poor reception).

Various ‘physical processes and actor activities’ were involved, including the instructor’s decision to undertake the activity in the first place given the conditions, her flawed evacuation plan, and her failure to impart the gravity of the situation to the students and their teacher.

‘Technical and operational management’ failures shaped the instructor’s performance on the day; she had limited experience of gorge-walking activities and lacked competence for them, both of which shaped her response to the unfolding incident.
The centre’s field manager failed to check the weather map on the reverse side of the faxed weather report (this showed the correct forecast), did not cancel all gorge trips in response to the adverse weather conditions and failed to communicate his decision to cancel the downstream version of the trip.

‘Company management’ failures also played a role; the centre was operating under financial and production pressures, which ostensibly contributed to a poorly designed adventure program, a rush to get staff trained and competent for activities, and the use of only one instructor for activities during busy periods. The centre’s staff induction, mentoring and training programs, and risk-assessment and management systems, were also found to be inadequate.

At the ‘regulatory factors’ level, the absence of a regulatory or licensing body for outdoor activity centres at the time meant that unsafe practices could continue unchecked without reprisals.

Finally, at the ‘government policy and budgeting level’, a lack of legislation to oversee the provision of led outdoor activities also enabled the centre to continue engaging in unsafe practices.

All of the factors outlined in the Accimap combined in a way that enabled the tragic accident to happen. Of note is the fact that the decisions and actions made on the day by those involved were shaped by various factors at the higher levels of the Accimap diagram. Most of these were present long before the accident happened; without examination of existing practices and incident data, these failures remained unchecked and the activity centre continued to drift towards catastrophic failure.

Into The Future

Safe led outdoor activities are critical to ensuring a healthy and productive Australian population. The led outdoor activity industry is striving to minimise the occurrence of accidents and remove unnecessary risks but this effort is currently hampered by a general lack of understanding of accidents and the absence of a standardised accident surveillance system.

The human factors-based accident analysis, however, will provide the basis for the proposed accident and injury surveillance system; Accimap is highly comprehensive, covering decisions, actions and failures across an entire system, potentially leaving no stone unturned. In considering how failures at one level shape and influence behaviour at another, it removes the blame culture common to accident investigations and ensures that accident prevention strategies are appropriately focused.

In the case of the Mangatepopo gorge walking tragedy, although instructor and field-manager decisions and actions played a key role, the role of other systematic failures in shaping their performance is made clear. The approach is generic and easy to use, meaning that little training is needed before it can be applied by industry professionals, which is important because its success depends on them.

The analysis of the Mangatepopo incident presented in this article was based on the independent inquiry teams report to the trustees of activity centre involved. (Brookes, Smith, Corkill, 2009). For a full list of references please email editorial@australianmediagroup.com

By Dr Paul Salmon and Miranda Cornelissen

  • Paul Salmon is a Senior Research Fellow within the Human Factors Group at the Monash Injury Research Institute and holds an Australian National Health and Medical Research Council (NHMRC) post doctoral training fellowship in the area of public health.
  • Miranda Cornelissen is a research assistant and PhD candidate within the Human Factors Group at the Monash Injury Research Institute.

Source
Active Education Magazine
September 5, 2012

 

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