A re-post from visibleprocrastinations.wordpress.com March 4, 2016;
While researching a scenario used in a Remote Area First Aid course last weekend, I have been introduced to a whole new area of Outdoor Education literature that exists with respect to fatality analysis and the outcomes which inform fatality management – a process above, and separate to, safety management, risk assessment and risk management;
Safety planning can be mired in trivial detail, distorted by institutional practicalities, diverted by the requirements of insurance claim managers, confused by optimistic jargon (‘best practice’, ‘quality assurance’, ‘legally covered’) and captured by the promoters of particular training or accreditation schemes. It may be based on theories which have paid insufficient attention to the available empirical evidence from the outdoor education field and the wider literature on safety management. [Brooks (2003a)]
The focus has shifted too. The emphasis in the current standard (Standards Australia and Standards New Zealand, 1999) is very much the protection of organisations themselves from ‘something happening that will have an impact upon objectives’ … The possibility of serious physical harm seems very much tacked on the end in this description. I’d argue that in a hierarchy of adverse consequences, death or serious injury to persons involved is right at the top of things we want to avoid. [Hogan (2002)]
The primary references for this have been published by Dr Andrew Brookes (see reference list below), and includes Scouting within the description of Outdoor Education. The fatality analysis papers lists known Scouting fatalities within the data sets but would not be a comprehensive collection of these incidents. I recommend reading through the papers in order as they build a clear picture from the incident analysis. I feel that this set of papers gives an interesting view to then reapply to our standard risk management process to double check – ‘have we allowed for fatality management?’.
Why is this important?
For many Venturer level activities the program not only recommends, it defines, the removal of direct supervision of activities (eg. Queen’s Scout level Expeditions). The Outdoor Education literature is pretty clear that we are organising a high risk activity with this requirement;
Some would argue that there is educational gain in teaching individuals, or a group, outdoor skills and then slowly removing the supervision of those learners so that the students become increasingly dependent on their own skills and judgment. My contention is that society is not sympathetic to this approach when safety is compromised for the sake of education. This sentiment is supported by recent coroners’ reports into the death of participants on outdoor education programmes.. I find it difficult to justify the removal of direct supervision of activities involving high levels of risk. Further, I believe that management personnel who condone such practices are placing themselves at risk of criminal prosecution by doing so.. [Davidson (2005)]
In some instances the boys were unsupervised as part of a deliberate program aim, in one or other variation of the ‘boys taking an adult role’ theme that has entered some forms of outdoor education from the early twentieth century youth movements. … ‘Indirectly supervised’ (i.e. not directly supervised) expeditions for teenagers present a clear fatality risk if there is a possibility of the group encountering moving water or steep ground. [Brooks (2003b)]
From a Venturer Leader’s perspective this means;
i.) Enhanced supervision is required if encountering moving water or steep ground, and it is best avoided if supervision cannot be guaranteed. This includes if this terrain is at the periphery of a planned activity;
The tight supervision that organized instruction necessitates (in activities such as abseiling, or canoeing) should be in place while students are near steep ground or moving water, i.e. not only while the activity is in progress. The fact that students may actively escape supervision or take advantage of a supervisor’s inattention should be considered. [Brooks (2003b)]
ii.) An examiner, having worked through the training, planning, equipment and competence of a QS Expedition should also ensure that a deviation from the planned route does not result in an unaccompanied party encountering moving water or steep ground; there would be a legal debate regarding Duty of Care owed if an unaccompanied party was to get into trouble under these conditions “a knowable event”. Has the examiner met the task of minimising the risk exposed by the identified hazards, such that the risk is reduced to an acceptable and justifiable level for the educational outcomes achieved?
The literature is also very clear that a supervisor should have local knowledge of the area being used for the expedition. These issues have also been given further weight via coronial reports (see Davidson (2005)).
In the two examples, both groups had received training prior to the unaccompanied trip, had been well equipped and had been deemed competent to undertake the trip by an experienced instructor who had observed them in similar terrain. In both cases, when hazardous terrain was encountered, and the group made poor judgments on the ways to deal with those hazards, no experienced leader was able to intercede and prevent serious injury from occurring. [Davidson (2005)]
Teenagers generally are more willing than adults to gamble what they can’t afford to lose. It is not that teenagers feel invulnerable, or do not weigh up risks and benefits, but rather they will make bad choices more often than adults if left unmonitored, and might be willing to try things adults would not contemplate. [Brooks (2007)]
This would require that all unsupervised expeditions have an analysis of what hazards exist if the group were to get off route. (In practice, the easiest way to ensure the hazards are managed is to shadow the group and move into the group when hazards are encountered. This method is now the recommended practice outside of Scouting.)
Several extremely important precautionary recommendations come from Brookes’ research;
1.) SUPERVISION: Teenagers, especially boys, must be effectively supervised around steep ground and moving water, especially at times when they are not involved in an organised activity. In hazardous conditions they (particularly boys) can tend to take risks that adults would not, most specifically around steep drops and moving water.
Teenagers generally are more willing than adults to gamble what they can’t afford to lose. It is not that teenagers feel invulnerable, or do not weigh up risks and benefits, but rather they will make bad choices more often than adults if left unmonitored, and might be willing to try things adults would not contemplate. [Brooks (2007)]
2.) The importance of planning how to coordinate an emergency response, including being able to detail your exact location and how it can be accessed by paramedic assistance. Fatality prevention requires emergency communication to be planned and tested, including contingency arrangements should the preferred method fail.
… the incident reinforces the observation that an emergency involves a ‘change of state’ from what may be a well-planned activity to a new and different activity that might not be well planned. Trip planning should include planning access for emergency services, and working through how to communicate locations unambiguously and effectively. [Brooks (2007)]
3.) ALLERGIES: The need for supervisors to understand and be prepared for severe allergic reactions. The timely use of an Epipen can save a student’s life.
4.) To view large-scale visits to pools or other swimming locations with considerable caution (particularly ‘end of the year’ celebrations)
5.) BULLYING: To be aware that outdoor activities might offer particular opportunities for bullying or worse, as “these particular behaviours tend to occur when the attention of supervisors is otherwise engaged, even if momentarily”.
6.) WEATHER: Weather can render a usually safe activity unsafe.
Environmental circumstances, including weather, remain paramount. A change of weather can move an activity beyond the boundaries that were planned for, creating a new unmanaged activity.
Many of the incidents here occurred when weather conditions transformed a planned activity into something completely different. [Brookes (2004)]
7.) ENVIRONMENT: The environment is a more important factor than the activity undertaken for educational activities involving dependent youth. There are exceptions (such as downhill skiing), but in many instances the only relevance of the activity is that it explains why the group or individual were in the fatal location. Activity skill might be a more important factor in some forms of adult recreation.
Outdoor education fatality prevention, at least in principle, should focus primarily on environmental hazards. Activity expertise is not sufficient to ensure fatality prevention. For fatality prevention, supervisors must have the knowledge and experience to recognise, and avoid or neutralise hazardous environmental conditions.
Rescue situations involve what is often a sudden ‘change of state’ from normal operations. Teachers or supervisors can find themselves transported from a situation that is well-planned and comfortably within their experience to a situation that is unplanned, unplanned for, and outside their experience in a matter of minutes. Rescue planning requires specific, deliberate attention in any fatality prevention process; it cannot be assumed that because a program runs smoothly and has a good record it will not descend into chaos in a rescue situation. [Brookes (2003b)]
… outdoor education involves novices; fatality prevention can hardly be based on presumptions of expertise. All students make mistakes, and most students learn only some of what they are taught. Students may become ill and unable to exercise skills they have. Participants in some forms of outdoor recreation may seek out situations in which there is little margin for error, but outdoor education, like all education, requires situations in which it is safe to make mistakes. [Brookes (2004)]
8.) To prevent fatal incidents supervisors must attend to supervision and environmental hazards for the entire duration of an outdoor education excursion. Safety planning which focussed just on the activities would fail to account for the many incidents which occur before and after planned activities, or which involve a victim who was not actually participating at the time.
9.) Adult supervisors can be victims
10.) FIRST AID & RESCUE: First aid failures are hardly ever identified as contributing to a death, but rescue glitches (i.e. logistical problems) sometimes are. First aid can save lives in certain kinds of situations, but most incidents are not of that kind. If a Risk Management Plan is only covering first aid and is ignoring rescue/evacuation it is not managing the higher risk issue;
… it is clear that not many, if any, fatal outcomes were contingent on the quality of first aid provision. Rescue is another matter. Rescue and first aid are linked to the extent that ‘seek qualified medical assistance promptly’ is a first aid imperative, but rescue also includes retrieving a situation before it becomes a first aid matter or worse. I found evidence to support the view that better planning for a possible rescue could have saved lives. [Brookes (2003b)]
11.) Informal excursions can be prone to problems due to lack of clarity about supervision responsibilities
REFERENCES:
Brookes, A. (2003a). Outdoor education fatalities in Australia 1960-2002. Part 1. Summary of incidents and introduction to fatality analysis.
Australian Journal of Outdoor Education, 7(1), 20-35.
Click to access brookes_a_OE-Fatalities1.pdf
Brookes, A. (2003b). Outdoor education fatalities in Australia 1960-2002. Part 2. Contributing circumstances: supervision, first aid, and rescue.
Australian Journal of Outdoor Education, 7(2), 34-42.
Click to access brookes_a_OE-Fatalities2.pdf
Brookes, A. (2004). Outdoor education fatalities in Australia 1960-2002. Part 3. Environmental circumstances.
Australian Journal of Outdoor Education, 8(1), 44-56.
Click to access brookes_a_OE-Fatalities3.pdf
Brookes, A. (2007). Research update: Outdoor education fatalities in Australia.
Australian Journal of Outdoor Education, 11(1), 3 – 9.
Click to access brookes_a_oe_fatalaties_in_Australia.pdf
Brookes, A. (2011). Research update 2010: Outdoor education fatalities in Australia.
Australian Journal of Outdoor Education, 15(1), 35 – 55.
https://www.researchgate.net/publication/326084604_Research_update_2010_Outdoor_education_fatalities_in_Australia
Davidson , G. (2004) Unaccompanied Activities in Outdoor Education
New Zealand Journal of Outdoor Education, 1(4),
Click to access UnaccompaniedActivities_Davidson_NZJOE_2005.pdf
Hogan, R. (2002). The Crux of Risk Management
Australian Journal of Outdoor Education, 6(2), 71 – 79
Click to access Hogan2002V6N2RiskManagement.pdf
Rather than list other references, it is worthwhile using the reference lists within these papers to expand the reading list.
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