outdoor north wales forum llanrwst march 2014 human error accidents marcus bailie head of inspection...
TRANSCRIPT
Outdoor North WalesForum
LlanrwstMarch 2014
Human Error Accidents
Marcus Bailie
Head of Inspection
Adventure Activities Licensing Service
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
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
The Lemon Theory – a climbing example
1. The climber falls off, jumps off or lets go.
2. The belayer wasn’t concentrating.
3. No-one ‘tailing’ the rope.
4. Instructor focused elsewhere.
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
Human Factors in Flight Safety
Flying isn’t dangerous,
but crashing is!
Error-nomics
Error-nomics
Why we make mistakes and what we can do to avoid them.
Joseph T. Hallinan
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.
What bridge?
Failing to leave a motorway where you had intended to?
Mind somewhere else!
Why the differences?
Pilots and Surgeons
In North America
The 90% Testor
How well calibrated are you?
1. The population of the USA in 2012?
2. The population of the UK in 2011?
3. The height of Everest in meters
4. The number of people in UK who died in 2011?
5. The number of workers who had fatal accidents at work in 2012/13?
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
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.
