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Wilderness Risk Management Conference 2012
Transcript of Wilderness Risk Management Conference 2012
the importance of the near miss Joshua Cole
Program Director, Northwest Outward Bound School
Guide, North Cascades Mountain Guides Steve Smith
National Director of Risk Management and Safety, Student Conservation Association 10 Minor Injuries 30 Property Damage Accidents What are you seeing? What incident data do you collect?
What do you do with your incident data?
How many near misses occur in your organization?
How many get reported?
What do you do with your near miss reports? Is your incident data useful? Incident data from Outward Bound (2008 - 2011) shows no statistical correlation between incident rate and location / course type Course Leader
Weeks # Courses # incidents / evacuations Evac Rate / 1000 days 0-50 51-100 100+ 48 21 16 46/25 14/10 16/10 1.23 1.13 1.42 Team Weeks # Courses # incidents / evacuations Evac Rate / 1000 days 0-50 51-100 100+ 31 25 29 26/15 25/14 25/16 1.16 1.31 1.27 Schimelpfenig, Leemon, Sibthorp, WRMC 2007 "We found no significant relationships between course leader or instructor team seniority and evacuations and risk management incidents" "It may be that many incidents are so idiosyncratic that experience alone is not a significant factor in preventing them. However, experience may help in how incidents are managed, or it may prevent a catastrophic incident" The importance of near miss incidents: What is the ratio
of near misses to
minor incidents to
in your program? SCA Reported Near Misses:
2012: 54 The things that cause near misses are the same things that cause accidents If we can identify and minimize those causes, we can reduce the likelihood of a serious incident Making reporting easy
Weekly positive reinforcement in program/risk mgt team meetings
Providing tools for better debriefs OSHA: "an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred" Quotes from Leemon et al. Components of James Reason's "Safety Culture" Reporting culture
Learning culture How does SCA try to learn from incidents and near-misses? What are your organization's barriers to accurately reporting and debriefing incidents/near-misses? How will you create culture and train staff to accurately report and assess near miss incidents? definitions Cautions Legal considerations
Over emphasis on near misses can distract from causes of actual injuries Medical - A student is injured or becomes ill
Behavioral - Significant intervention is necessary due to student behavior near miss incident Overcoming Barriers:
Cultivating a "Safety Culture" Daniel Kahneman: The confidence we experience as we make a judgment is not a reasoned evaluation of the probability that it is right. Confidence is a feeling, one determined mostly by the coherence of the story and by the ease with which it comes to mind, even when the evidence for the story is sparse and unreliable. Educational Outcomes 1. If you want to make an accurate assessment, you have to understand your incident data, and the limitations therein.
2. To improve risk management, particularly reduction of significant incidents, place emphasis on thoughtful assessment of near miss data.
3. If you want to understand and utilize near misses, you must create a culture around them. Action Steps 1. Assess your organizational culture around safety
2. Identify the barriers in your organization that inhibit the culture that you are trying to build
3. Explore if the way you are collecting and analyzing data is consistent with the culture that you are trying to build