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Outdoor North Wales Forum Llanrwst March 2014

Outdoor North Wales Forum Llanrwst March 2014. Human Error Accidents Marcus Bailie Head of Inspection Adventure Activities Licensing Service. The problem.

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Outdoor North Wales Forum Llanrwst March 2014

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  1. Outdoor North WalesForumLlanrwstMarch 2014 Human Error Accidents Marcus Bailie Head of Inspection Adventure Activities Licensing Service

  2. The problem • A teacher seriously injured (paraplegic) because an instructor didn’t connect the safety rope to the back of her harness before she jumped from a platform. • An instructor failed to ‘equalise’ the ends of his abseil rope and abseiled off the end. • An adult client fell from a zip wire because the instructor failed to attach her correctly to the trolley. • Student injured on a high ropes course because no-one noticed that the belayer had walked away! • An 11 year boy died when an instructor incorrectly attached him to a zip wire

  3. Accident Theories • Mechanical failure • Instructor incompetence • Instructor inexperience • Flawed operating system • Violation • The Domino Theory • Attitude to Risk • Bad luck • The Lemon Theory – unrelated contributory causes • Human error accidents

  4. The Lemon Theory – a climbing example • The climber falls off, jumps off or lets go. • The belayer wasn’t concentrating. • No-one ‘tailing’ the rope. • Instructor focused elsewhere.

  5. Human Factors • Client pressure • Peer pressure • Task overload • Fatigue • Panic • The Plan B barrier • Incorrect assumptions - Negative reinforcement and the turkey trap • All eggs in one basket • Inattention

  6. Human Factors in Flight Safety Flying isn’t dangerous, but crashing is!

  7. Error-nomics Error-nomics Why we make mistakes and what we can do to avoid them. Joseph T. Hallinan

  8. Error-nomics • The problems with accident investigation • Not all sectors have the same accidents or accident rates: - Farming, off-shore fisheries, construction - Office work, service industries • When we aren’t focused we make mistakes, and when we make mistakes we have accidents.

  9. What bridge? Failing to leave a motorway where you had intended to? Mind somewhere else!

  10. Why the differences? Pilots and Surgeons In North America

  11. The 90% Testor How well calibrated are you? • The population of the USA in 2012? • The population of the UK in 2011? • The height of Everest in meters • The number of people in UK who died in 2011? • The number of workers who had fatal accidents at work in 2012/13?

  12. Minimising human error • Ensure instructors are competent • Avoid the need to multi-task – the moonwalking bear • Avoid repetitive tasks – variety is the spice … • Lots of breaks - swimming pool life-guards • Multi-competent leaders – different repetitive tasks • Group instructors • Pre-flight mental check-lists • Use participants – participants not passengers

  13. Monitoring • Walking the Floor • Managerial or technical • Spotting problems – specific and general • Knowing what actually goes on out there • Nurturing staff • What they do is important • If they think you don’t care - then they won’t • If they don’t care they’ll have accidents.

  14. Thank you! Marcus Bailie 029 2075 5715 Adventure Activities mbailie@aals.org.uk Licensing Service

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