Keynote - Accident Research - Monash University

www.monash.edu.au/muarc

The role of Human Factors in outdoor led activity accidents and incidents: y

Literature review and exploratory case studyy

Dr Paul SalmonMs Amy Williamson

Ms Eve Mitsopoulos-RubensCDr Christina Rudin-Brown

Dr Michael Lenne

H F G

1

Human Factors Group, Monash University Accident Research Centre


Content

M h U i it A id t R h C t

Content

• Monash University Accident Research Centre• Project background

I t d ti t H F t• Introduction to Human Factors• Accidents and accident causation models• Literature review findings• Accident analysis methods• Case study analyses• Future directions


The Human Factors Group, MUARCThe Human Factors Group, MUARC

3


Team CapabilitiespResearch Themes:• Human Performance

Research Methods:• Data collection e.g. obs study, interviews etc

• System Performance• Organisational and Cultural Factors

Psychological Constructs:

g y• Task analysis e.g. Hierarchical Task Analysis• Cognitive task analysis e.g Critical Decision

Method• Situation awareness measurement e.g. Psychological Constructs:

• Distraction• Decision making• Situation awareness

gSAGAT

• Teamwork assessment e.g. EAST• Workload measurement e.g. NASA TLX• Human error prediction & analysis e.g.

• Human error• Workload• Training • System design and evaluation

p y gSHERPA

• Usability & Interface evaluation e.g. SUS, Checklists

• System design e.g. Cognitive Work Analysisy g• Accident Analysis• Simulation & instrumented vehicles


Our expertise and areas of potential workplace applicationOur expertise and areas of potential workplace application• Impairment

Alcohol cannabis• Technology

I t lli t S d Ad t ti– Alcohol, cannabis– Driver drowsiness– Operator inexperience

Ageing and disability

– Intelligent Speed Adaptation– Advisory warning systems– Human-machine interface

Development and validation of a– Ageing and disability

• Training and skill developmentD l t d l ti

– Development and validation of a distraction test

• Systems of workProblem definition to inform– Development and evaluation

of a driver training product– Hazard perception– Communication-based

– Problem definition to inform solutions

– Task analysis– System design– Communication-based

training programsSystem design

– Systems-based accident analyses

– Organisational safety


Accident analysis & investigationy g


Dr Paul SalmonDr Paul Salmon• BSc Sports Science, MSc Applied Ergonomics, PhD

Human FactorsHuman Factors• Human error theory, analysis and prediction• Situation awareness• Situation awareness• Teamwork• Human Factors methodsHuman Factors methods• Task analysis• Cognitive task analysisg y• Systems theory• Sociotechnical system design


Project BackgroundProject Background


BackgroundBackground

• Initiated by outdoor activity sector• Initiated by outdoor activity sector

• Department of Planning and CommunityDepartment of Planning and Community Development, Sports & Recreation Victoria

N ti l St t d i ti l b di• National, State and organisational bodies

• Australia Camps AssociationAustralia Camps Association

• Research monitored by an industry appointed i i i i i fsteering committee, comprising representatives from

several organisations


StakeholdersStakeholdersNational• Australian Camps Association• Australian Camps Association• Christian Venues Association• Outdoor Council of Australia State• Sport and Recreation Victoria• ORIC NSW• VOEA Vic

ORC Vic• ORC Vic• QORF Qld• Outdoors WAOrganisationsOrganisations• YMCA• OEG• Bindaree• Outward Bound• Halls


3 Stage Program3 Stage Program

f f1. Identification of the Human Factors issues involved in accidents and incidents

2. Establishment of industry database and integration of industry reporting with database

3. Implementation of measures to reduce injury p j yand ongoing reporting of incident data


Stage 1 aimsStage 1 aims

f• To gain a better understanding of the involvement of Human Factors in led outdoor

i i id d i idactivity accidents and incidents


Stage 1 aimsStage 1 aims

f• To gain a better understanding of the involvement of Human Factors in led outdoor

i i id d i idactivity accidents and incidents• “facilitated or instructed activities within

outdoor education and recreation that have a learning goal associated with them”


Research undertakenResearch undertaken

1 Literature review1. Literature review– To ascertain what is currently known about accidents and

incidents in led outdoor activity– Identify Human Factors issues

2. Exploratory case study analysis2. Exploratory case study analysis– Three systems-based accident analysis methods applied to

three led outdoor incidents

3. Workshop


What is Human Factors?What is Human Factors?


Human FactorsHuman Factors

• “the scientific study of the relationship between man and• the scientific study of the relationship between man and his working environment” (Murell, 1965)

“ h d f h h li h k l d k• “the study of how humans accomplish work-related tasks in the context of human-machine systems” (Meister, 1989)

• “applied information about human behaviour, abilities, limitations and other characteristics to the design of tools, machines, tasks, jobs and environments” (Sanders & , , j (McCormick, 1993)

• Studying and enhancing the performance of sociotechnicalStudying and enhancing the performance of sociotechnical systems


Accidents and accident causationAccidents and accident causation


AccidentsAccidents

• Latin verb ‘accidere’ = ‘to happen’• ad + cadere = ‘to fall’• “a short, sudden, and unexpected event or

occurrence that results in an unwanted or indesirable outcome” (Hollnagel, 2004)

• Event or occurrence directly or indirectly theEvent or occurrence directly or indirectly the result of human activity


Human error

“ i t t ll th

Human error

• “a generic term to encompass all thoseoccasions in which a planned sequence ofmental or physical activities fails to achieve itsmental or physical activities fails to achieve itsintended outcome, and when these failurescannot be attributed to the intervention of somechance agency” (Reason, 1990, p. 9).


Theoretical perspectives

P h ( ld i )

Theoretical perspectives

• Person approach (or old view)- Errors at the ‘sharp end’- Errors result from psychological/physical factors withinErrors result from psychological/physical factors within individuals

- Individual focussed strategies and countermeasures• Systems approach (or new view)

- Error as a systems failure- Human error as a consequence of latent conditions residing- Human error as a consequence of latent conditions residing throughout the system

- Systems-based strategies and countermeasures


Systems versus person perspectives


“C l t t b d t d b“Complex systems cannot be understood bystudying parts in isolation. The very essence

f th t li i th i t ti b tof the system lies in the interactions betweenparts and the overall behaviour that emergesf th i t ti Th t t bfrom the interactions. The system must beanalysed as a whole” (Ottino, 2003)


Swiss Cheese model of human error (Reason 1990)Swiss Cheese model of human error (Reason, 1990)

Reason, J. (1990). Human Error. New York, Cambridge University Press.


Rasmussen’s risk management framework


Herald of Free Enterprise Zeebrugge disasterHerald of Free Enterprise Zeebrugge disaster

• March 6th 1987Ferry capsized• Ferry capsized

• 150 passengers & 38 crew killed

• Ferry set sail with inner bow doors open


Herald of Free Enterprise Zeebrugge disasterHerald of Free Enterprise Zeebrugge disaster

Assistant bosunsfailure to shut

bow doors

Captains leaves port with bow Doors open

Fatigue

Choppysea

Negativereporting culture

Pressure todepart early

‘N t j b’

Poor rosteringInherent unsafe ‘top heavy’ ferry design

‘Not my job’Culture

Failure to install bowDoor indicator


Systems approach predictions (Rasmussen 1997)Systems approach predictions (Rasmussen, 1997)

• Safety is an emergent property impacted by decisions of all actors not• Safety is an emergent property impacted by decisions of all actors, not just front line workers alone

• Threats to safety are caused by multiple contributing factors, not just a single catastrophic decision or actionsingle catastrophic decision or action

• Threats to safety can result from a lack of vertical integration across levels of a complex sociotechnical system, not just from deficiencies at one level alone

• Lack of vertical integration is caused, in part, by lack of feedback across levels of a complex sociotechnical system

• Work practices are not static, the migrate over time and under the p , ginfluence of financial and psychological pressures

• Migration occurs at multiple levels of complex sociotechnical systems• Migration of work practices cause system defences to degrade and g p y g

erode gradually over time, not all at once. Accidents are caused by a combination of this migration and a triggering event(s)


Literature review findingsLiterature review findings


Existing accident modelsExisting accident models

S (• Some models exist (e.g. Bentley et al, 2001; Davidson, 2007; Meyer, 1979)

• Lack of theoretical underpinningp g

• Absence of wider systemic failures• Absence of wider systemic failures

• Limited applications


Meyer (1979)Meyer (1979)


Root cause model (Davidson, 2007)


Root causes taxonomy (Davidson 2007)Root causes taxonomy (Davidson, 2007)

O l d l k f l it• Overload e.g. lack of personal capacity, poor physical/mental condition, traps in the work environmentenvironment

• Poor concentrationMi li ti f kill• Misapplication of skills

• Poor judgement e.g. poor situation i t t f i kawareness, inaccurate assessment of risk

• Failing to meet judgement responsibilities• Misdirected motivation/attitudes


Key Human Factors issues?yInstructor/ student factors Sources

Risk management Boyes & O’Hare 2003 Hogan 2002 American Camp Association Capps 2007Risk management Boyes & O Hare 2003, Hogan 2002, American Camp Association, Capps 2007, Wilks & Davis 2000, Brown 1995, Davidson 2004, Brookes 2003, Powell 2007,

Cline 2007, Hunter 2007, Harper & Robinson, 2005).

Failure to record near misses Brackenreg 1999, Capps 2007, Brookes 2003, Watters 1996, Davidson 2004, Haddock 1999.

Risk perception Dallat 2007, Dickson Chapman & Hurrell 2000, Powell 2007, Brown 1995, Cline 2007.

Leadership Boyes & O’Hare 2003, Galloway 2002, Harper & Robinson 2005, Brookes 2003, Leadership y , y , p , ,Wilks & Davis 2000, Brown 1995, Davidson 2004.

Instructor qualification Crosby & Bensemen 2003, Wilks & Davis 2000, Australian Canoeing, Brookes 2003.

SupervisionSupervisionDavidson 2001 and 2004, Brookes 2002 and 2003.

Decision making Ewert, Shellman & Glenn 2006, Boyes & O’Hare 2003, Watters 1996, Galloway 2002, Wickens & Hollands 2000.

Situation awareness Boyes & O’Hare 2003 Galloway 2002Situation awareness Boyes & O Hare 2003, Galloway 2002.

Complacency and fatigue Hunter 2007, Haddock 1999, Davidson 2004, American Camp Association.


Instructor/ student factors

Hazards arising from instructor and student attitudes Brackenreg 1999Hazards arising from instructor and student attitudes, skills and behaviours

Brackenreg 1999

Client unsafe acts i.e. inadequate protection, instruction

Meyer 1979, cited in Davidson 2004

Judgement errors on behalf of the instructor Meyer 1979, cited in Davidson 2004

Poorly skilled/ trained instructors Meyer 1979, cited in Davidson 2004

Overload Davidson 2004

Poor concentration Davidson 2004

Misapplication of skills Davidson 2004

Poor judgement Davidson 2004

Failing to meet judgement responsibilities Davidson 2004


Wider systems factorsWider systems factors

Hazards in the local surroundings Brackenreg 1999

Hazards associated with the activity Brackenreg 1999

Environmental conditions i.e. falling rocks, weather, inadequate security, equipment, clothing

Meyer 1979, cited in Davidson 2004

Poor safety management Davidson 2004

Poor implementation of safety management system Davidson 2004


So what?So what?

O• Only limited research undertaken• Current knowledge of causal factors is limited• Existing models lack depth and theoretical

underpinningp g• Failure to consider wider systemic factors• No universally accepted model or taxonomy• No universally accepted model or taxonomy• Limited evidence of applications of models• Lack of spin in from other domains


Accident and incident databasesAccident and incident databases


Reporting systems and Incident databasesReporting systems and Incident databases• Widely accepted approach and commonly used in

most safety critical domainsmost safety critical domains

• Widely recognised as a key provision in the outdoor• Widely recognised as a key provision in the outdoor activity sector (Davidson 2004, Curtis, Brackenreg 1999, Haddock 1999, Brookes 2003, 2007)

• Used for various purposes> In-depth studies> In depth studies> Error trends> Development of domain-specific taxonomies of error

E l i> Error analysis> Inform the development of countermeasures


Current Incident DatabasesDatabase Country ActivitiesDatabase Country Activities

International Incident Database Project

USA - Headed by a working group- an international consortium of program and risk managers in the outdoor ed field, initiated by Risk Curtis- Aims to define an international standard for collecting incident data- Define key elements essential to incidents- Define key elements essential to incidents- Create a common, accessible database to integrate data from around the world- Project website built as an application model for the outdoor community

National Incident Database NZ - NZ Mountain Safety Council, Outdoors NZ, Education Outdoors NZ, Ministry of Ed- Online incident data collection and analysis tool using a standard method- Launched in 2004, now contains over 15 745 incidents- Works towards creating an international standard to integrate data- Identify trends, increase understanding about risks and causal factors- Voluntary and anonymous with growing support

S C ti f td h l d i tiWilderness Risk Managers Committee Incident Reporting Project

USA - Consortium of outdoor schools and organisations - Collection and management of data with the aim of better understanding risk- Sponsored by NOLS- recently concluded (2009) - Over 65 organisations submitted data, 1195 incident records

Outdoor Medical Incident Australia - Incident recording and management system designed to help organisationsOutdoor Medical Incident Database

Australia Incident recording and management system designed to help organisations manage risk- Outward Bound Australia- 3 years

National Accident Incidence Report Form Database

Australia - Voluntary reporting database to assist organisations in the review of their operations

Australian Accident Database Australia - List of accident, including near misses that have occurred in the outdoor and adventure environment - Now covers all of Australia- Established as a readily accessible learning tool


So What?So What?

C f• Current state of incident reporting in the led outdoor education industry is fragmented

• Lack of a standardised data collection, storage, and analysis system

• Data quality• Lack of appropriately trained investigatorsLack of appropriately trained investigators• Close ranks culture


Other complex safety critical domains?Other complex safety critical domains?

S f S• Aviation Safety Reporting System• NTSB accident database• Theoretically underpinned, systems-based

accident analysis e.g. HFACSy g• Systems-based countermeasures• Boeing Safety Management System• Boeing Safety Management System


Exploratory case study analysesExploratory case study analyses


AimAim

• To ascertain whether systems approaches are applicable in the led outdoor activity domain

• To determine which of three approaches is the most suitable for analysing, and learning from, led outdoor activity accidents and incidents


HFACS (Shappell & Wiegmann 2003)HFACS (Shappell & Wiegmann, 2003)

A i ti id t i ti ti h• Aviation accident investigation approach• Based on Reason’s Swiss Cheese model• Applications in a range of domainsApplications in a range of domains

- General aviation - Maritime- Mining- Rail

R d t t- Road transport- Construction


AcciMaps (Rasmussen 1997)AcciMaps (Rasmussen, 1997)• Graphically represent accident causation trajectories

Si i ti l l l• Six organisational levels- Govt policy and budgeting;- Regulatory bodies and associations;Regulatory bodies and associations;- Local area Govt planning & budgeting;- Technical operation and management;- Physical processes and actor activities;- Equipment and surroundings.

A li d t f id t i l di l t l i• Applied to range of accidents including gas plant explosions (Hopkins, 2000), loss of space vehicles (Johnson & de Almeida, 2008), aviation accidents (RAAF, 2001), public health (Vicente & Christoffersen; 2006), and road and rail accidents (Svendung & Rasmussen, 2002; Hopkins, 2005). Applicable to catastrophic failures in any domain……………………


Example output

Jenkins, D. P., Salmon, P. M., Stanton, N. A., & Walker, G. H. (In Press). A systemic approach to accident analysis: a case study of the Stockwell shooting. Ergonomics


Root cause model (Davidson, 2007)


Case study accidentsCase study accidents

• Lyme Bay Kayaking tragedy

• Ripswing incident

• Entrapment and near drowning incident


The Lyme Bay Kayaking TragedyThe Lyme Bay Kayaking Tragedy

• Introductory open sea kayak activity• Initial capsizes• Group becomes separated and swept out to

sea• High wind and wave conditions lead to further

capsizes and abandoning of kayakscapsizes and abandoning of kayaks• Delayed rescue

4 t d t d d• 4 students drowned


Lyme Bay Root cause model analysisLyme Bay Root cause model analysis

Instructor root causes• Mismatch of skills/Experience• Equipment traps• Environment trapsEnvironment traps• Poor judgement

I t t f i k• Inaccurate assessment of riskManagerial root causes• Poor safety management systems


Lyme Bay Accimap


Lyme Bay HFACS output


Systems-based accident analysis?


Validation of Rasmussen’s frameworkValidation of Rasmussen’s framework

• Safety is an emergent property impacted by decisions of all actors not• Safety is an emergent property impacted by decisions of all actors, not just front line workers alone

• Threats to safety are caused by multiple contributing factors, not just a single catastrophic decision or actionsingle catastrophic decision or action

• Threats to safety can result from a lack of vertical integration across levels of a complex sociotechnical system, not just from deficiencies at one level alone

• Lack of vertical integration is caused, in part, by lack of feedback across levels of a complex sociotechnical system

• Work practices are not static, the migrate over time and under the p , ginfluence of financial and psychological pressures

• Migration occurs at multiple levels of complex sociotechnical systems• Migration of work practices cause system defences to degrade and g p y g

erode gradually over time, not all at once. Accidents are caused by a combination of this migration and a triggering event(s)


Lyme Bay Accimap


Generic failure typesLACK OF

LEGISLATION

FAILURE TO INADEQUATE

LACK OFREGULATORY BODY

FAILURE TO INSPECT CENTRE

ACTIVITY/DEVICEOVERLOOKEDIN STANDARDS

FAILURE TO IDENTIFY UNSAFE

PRACTICEVOLUNTARY

SCHEME ONLY

INADEQUATEPROCEDURES

INAPPROPRIATERECRUITMENT

FAILURE TO COMPLYWITH LEGISLATION

FAILURE TOASSESS RISKS

INADEQUATESUPERVISION CULTURE

FAILURE TO RESPONDTO REGULATORY BODY

REQUESTS

FAILURE TO RESPONDTO SAFETY CONCERNS

INADEQUATELY QUALIFIED

INAPPROPRIATEACTIVIITY

FAILURE TOCHECK WEATHER

POOR SITUATIONAWARENESS

INADEQUATETRAINING

POOR COMMS

FAILURE TO COMPLYWITH LAW, PROCEDURES INEXPERIENCE VIOLATIONS

SKILL-BASEDERRORS

DECISIONERRORS

VIOLATIONS WRONGACTION

POOR COMMS

FAILURE TOFOLLOW

PROCEDURES

ACTIONTOO LATE

MISTAKE

LAPSE INEXPERIENCE

INAPPROPRIATE EQUIPMENT

EQUIPMENTNOT PROVIDED

INAPPROPRIATE USE OF

EQUIPMENT

UNSAFEDESIGN

ENVIRONMENTALCONDITIONS

EQUIPMENTFAILURE

NO FAIL SAFE

UNSAFEEQUIPMENT


The way forward?The way forward?


Data challengesData challenges

“I l t t l“In complex systems, event analyses areconstrained by the quality of the data

th d th t it f th i t dgathered, the maturity of the associatedreporting system, and the training andb k d f th i ti t d tbackground of the investigator and reporter.Such constraints place limits on the adequacy

d t th f l d t d ith thand strength of analyses conducted with thedata.”(Grabowski et al, 2009)


Data and analysis challengesData and analysis challenges

St d di d i id t ti t• Standardised incident reporting system• Standardised accident and incident database• Systems-based accident analysis method• Investigator training in HF/systems-based models• Outdoor activity contributory factor taxonomies• Instructor/student error taxonomies• In-depth analysis


BenefitsBenefits

St d f id t id l t d f• Study of accidents widely accepted as a way of acquiring knowledge that can improve safety (e.g. Cassano-Piche et al, 2009), )

• Quality of knowledge dependent on data, analysts and theoretical/methodological frameworks that guide the

l ianalysis• Development and application of standard, universally

accepted theoretically underpinned data collectionaccepted, theoretically underpinned data collection, storage and analysis approaches will lead to an increase in knowledge, the appropriate application of

hi h i lik l t l d t d ti i f twhich is likely to lead to a reduction in safety compromising accidents and incidents


Thanks very much for the opportunity!Thanks very much for the opportunity!

Questions?

paul salmon@muarc monash edu [email protected]

Keynote - Accident Research - Monash University

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