Op#mising)incidentrepor#ng)systems) for)learning ......Op#mising)incidentrepor#ng)systems)...

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Op#mising incident repor#ng systems for learning: a systems thinking approach Dr Natassia Goode Research Fellow, USCAR

Transcript of Op#mising)incidentrepor#ng)systems) for)learning ......Op#mising)incidentrepor#ng)systems)...

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Op#mising  incident  repor#ng  systems  for  learning:    

a  systems  thinking  approach  

Dr  Natassia  Goode  Research  Fellow,  USCAR  

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S#ll  a  significant  problem  in  Australia.  

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Never  again!     We  must  learn  from  this  event!  

There  is  liGle  evidence  that  organisa#ons  are  learning  from  incidents  and  near  misses  in  the  workplace.  

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A  long  series  of  steps  towards  learning…  Iden#fying  

events  worth  repor#ng  

Repor#ng  

Analysing  

Decision-­‐making  

Implementa#on  

Follow-­‐up  

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The  problem…models  of  accident  causa8on  

Star#ng  machinery  without  warning  

Lack  of  supervision  

Lack  of  training  

Lack  of  guard  rails  

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The  problem…models  of  accident  causa8on  

The  answer:  •  strict  supervision  •  remedial  training    •  discipline  

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An  alterna#ve:  the  systems  approach  1.  Safety  is  impacted  by  the  decisions  and  ac#ons  of  everyone  

in  the  system  not  just  front  line  workers.    

2.  Near  misses  and  adverse  events  are  caused  by  mul#ple,  interac#ng,  contribu#ng  factors.  

3.  Effec#ve  countermeasures  focus  on  systemic  changes  rather  than  individuals.  

The  goal  is  not  to  assign  blame  to  any  individual,  but  to  iden#fy  how  factors  across  the  system  combine  to  create  accidents  and  

incidents.  

  Why  haven’t  we  applied  this  understanding  to  the  analysis  of  workplace  injuries  and  near  misses?  

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The  UPLOADS  Project  Goal:  develop  a  standardised,  na#onal  approach  to  incident  repor#ng  and  learning  for  the  outdoor  ac#vity  sector  in  Australia  underpinned  by  a  systems  model  of  accident  causa#on.    Support:  Organisa#on  in  analysing  their  own  data;  and  The  collec#on  of  industry-­‐wide  data.  

 

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What  is  the  outdoor  ac#vity  sector?  

Horse  riding;  trail  biking;  caving;  bushwalking;  trail  running;  canoeing;  sailing;  mountain  biking;  slacklining;  rockclimbing;  orienteering;  surfing;  4WDing;  rogaining;  camping;  challenge  ropes  courses;  expedi#ons;  fishing;  kayaking;  snorkelling;  off  road  triathlons;  pioneering  …    

•  Recrea#on    •  Educa#on  •  Adventure    •  Therapeu#c    •  Developmental    •  Tourism    •  Skill  development    •  Community  engagement    •  Spiritual  development    

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Just  like  any  workplace  

WHS  Legisla#on:    They  hold  a  duty  of  care  towards  their  clients  and  employees.    They  must  eliminate  or  manage  the  risks  within  the  workplace  as  far  as  reasonably  possible.    

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High risks  

2007  -­‐  2009  there  were  five  fatali#es  in  commercial  ra_ing  opera#ons  in  Cairns.   Three different companies. Why?

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Prior  to  UPLOADS  what  was  known?  

•  A  liGle  about  the  ‘broken  component’  (e.g.  ac#vity  leader  failures)  

•  Limited  evidence  on  system  wide  failures  •  Poor  data  systems  •  Incident  repor#ng  limited  

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Project  Phases  1. Methodological  development.  Prototype  incident  repor#ng,  

storage  and  analysis  methods  was  developed,  forming  a  prototype  accident  &  injury  surveillance  system;  

2. Methodological  valida;on  and  refinement.    Prototype  system  was  trialled  and  evaluated  by  led  outdoor  ac#vity  providers;  

3. In-­‐depth  incident  study.  Injury  surveillance  system  will  be  implemented  in  order  to  conduct  an  in-­‐depth  study  of  injury  causing  incidents  in  the  led  outdoor  ac#vity  domain  in  Australia;  and  

4. Accident  causa;on  model  development.  Based  on  the  findings,  a  systems-­‐based  model  of  injury  incident  causa#on  for  the  led  outdoor  ac#vity  domain  will  be  developed.    

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UPLOADS  Data  Collec#on  System  The  system  consists  of:  1)  A  so_ware  tool  for  recording  injury  and  near  miss  data,  

tailored  to  the  outdoor  ac#vity  context;  2)  A  coding  framework  for  classifying  the  causal  factors  

involved  in  outdoor  injuries  and  near  misses.  The  framework  is  underpinned  by  a  systems  theory  model,  Rasmussen’s  Risk  Management  Framework.  

3)  Tools  for  analysing  the  causal  factor  data;  4)  Paper-­‐based  and  video  training;  and  5)  A  method  for  secure  and  confiden#al  contribu#on  to  the  

industry  database.  

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Coding  framework  development  1.  Comparison  of  systems-­‐orientated  accident  analysis  methods  for  the  

purposes  of  analysing  fatal  outdoor  accidents  (e.g.  HFACS;  STAMP;  and  Rasmussen’s  Framework-­‐  Salmon,  Cornelissen  &  TroGer,  2012).  

2.  Rasmussen’s  framework  was  then  adapted  to  describe  the  ‘led  outdoor  ac#vity  system’.    

3.  Analysis  of  over  1000  led  outdoor  incidents  was  then  undertaken  to  iden#fy  a  set  of  specific  causal  factors  involved  in  outdoor  incidents.    

4.  We  then  populated  the  framework  with  these  factors.  

5.  Reliability  tes#ng  –  14  safety  managers  from  outdoor  ac#vity  providers  coded  10  detailed  incidents,  revised  the  framework.  

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Coding  framework  State  and  Federal  Government  (8)  

Regulatory  bodies  and  professional  associa8ons      (8)  

Higher-­‐level  Management    (11)  

Parents/Carers    (6)  

Schools    (8)  

Local  Area  Government    (6)  

Supervisor/Field  Managers    (10)  

Ac8vity  Leader    (9)  

Ac8vity  Par8cipants    (8)  

Other  People  in  Ac8vity  Group    (9)  

Group  Factors    (8)  

Other  People  in  Ac8vity  Environment    (8)  

Ac8vity  Environment    (6)   Ac8vity  Equipment  and  Resources    (5)  

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Automa#c  tools  for  analysis  

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Secure  and  confiden#al  repor#ng  

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USCARUniversity of the Sunshine Coast Accident Research

UPLOADS:  summary  of  features  •  Based  on  a  systems  theory  framework.  

•  Specifically  designed  for  outdoor  ac#vity  providers.  

•  Systema#cally  track  incident,  staff  and  par#cipant  data.  

•  Tools  to  analyse  your  own  data.  

•  Video  and  paper-­‐based  training  material.  

•  Allows  you  to  contribute  deiden#fied  data  to  an  industry  database.  

•  Analysis  of  industry-­‐level  data  will  provide  evidence  to  support  systemic  changes.  

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But  will  it  improve  safety??  Iden#fying  

events  worth  repor#ng  

Repor#ng  

Analysing  

Decision-­‐making  

Implementa#on  

Follow-­‐up  

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USCARUniversity of the Sunshine Coast Accident Research

Thank  you!    

 

Dr  Natassia  Goode  

University  of  the  Sunshine  Accident  Research  Team  

[email protected]  

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USCARUniversity of the Sunshine Coast Accident ResearchKey  future  Human  Factors  Issues  in  

Safety  Science  

1.  We  need  a  method  for  developing  systems-­‐orientated  accident  analyses  into  systems-­‐orientated  recommenda#ons.    

2.  We  need  to  beGer  integrate  systems-­‐thinking  into  work  planning  and  design.  

3.  We  need  models  that  can  predict  when  the  normal  condi#ons  of  work  are  migra#ng  towards  the  boundaries  of  safety.  


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