prevention is not enough

Prevention is Not Enough

Vallorie Hodges and Fiona McCarthyCollaborators: Sidney Dekker, Ivan Pupulidy, Crista VeselJuly 2021

Today we are meeting on lutruwita (Tasmania) Aboriginal land, sea and waterways. I acknowledge, with deep respect the traditional owners of this land, the muwinina people, which we meet today.

The muwinina people belong to the oldest continuing culture in the world. They cared and protected Country for thousands of years. They knew this land, they lived on the land and they died on these lands. I honour them.

For the muwinina people, the area around nipaluna (Hobart) was their Country and they called Mount Wellington kunanyi.

I acknowledge that it is a privilege to stand on Country and walk in the footsteps of those before us. Beneath the mountain, among the gums and waterways that continue to run through the veins of the Tasmanian Aboriginal community.

I pay my respects to elders past and present and to the many Aboriginal people that did not make elder status and to the Tasmanian Aboriginal community that continue to care for Country.

I recognise a history of truth which acknowledges the impacts of invasion and colonisation upon Aboriginal people resulting in the genocide and forcible removal from their lands.

Our Island is deeply unique, with spectacular landscapes with our cities and towns surrounded by bushland, wilderness, mountain ranges and beaches.

I stand for a future that profoundly respects and acknowledges Aboriginal perspectives, culture, language and history. And a continued effort to fight for Aboriginal justice and rights paving the way for a strong future.

ACKNOWLEDGEMENT TO COUNTRY

Abstract

• Prevention bias is not robust• Complexity• High consequence events

• We cannot prevent all incidents

• Must balance prevention with capacity to respond and recover (Resilience)

Hodges & McCarthy, University of Tasmania July 2021

“Prevention is a powerful bias in our operational thinking”(T. Conklin)

All events are preventable

• We have good controls• The controls will hold

Misplaced confidence

What about Drift?


1. When you do this job, what will kill or hurt you?2. When that happens, what keeps you from dying?3. Is that enough?

Fail Safe approach

Three Questions (Conklin)

Prevention Task Execution Resilience

Three Pillars

Resilience EngineeringReference: Dekker, S. Foundations of Safety Science 2019 CRC Press pp.393


This Session

• Offers a Model – simple visual framework • Appreciative Inquiry Approach

• Stimulate dialogue• Promote learning and a shared

understanding• Safety Differently language

• An adaptation of the ‘bow tie’


Control: the Buddy System (team diving)


Mutual assistance and responsibility

• Effective two-way communication• Visual contact• Direct access

Duty to maintain

Immediately recognise a problem and render assistance

Anticipated Threats ImpactsRESPONSEEVENT


PREVENTIONWe cannot

eliminate all threats

We cannotcontrol all impacts

Presenter

Presentation Notes



PREVENTION



PREVENTIONWe cannot



EVENTEVENT


‘Team’ Diving



PREVENTIONWe cannot




Gareth Lock’s DEBRIEF model



PREVENTIONWe cannot



Emerging threats

Anticipated Threats Impacts


RESPONSEPREVENTIONWe cannot



Emergent threats

Recovery

EVENT

Does your investigation process support a restorative recovery from a serious event?

Investigation

Who is responsible?

Corrective ActionsPrevention


Learning Review

What is responsible?

Improvement ActionsPreventionTask ExecutionResponse






Emergent threats

Recovery

EVENT



PREVENTIONWe cannot



Emergent threats

Recovery



PREVENTION

Presenter

Presentation Notes

Pop the balloon

Impacts


RESPONSEEVENTPREVENTION

Impacts


RESPONSEEVENTPREVENTION

A strong prevention bias can lead to a failed or zero response

Presenter

Presentation Notes

Pop the balloon






Emergent threats

Recovery

EVENT


Simple visual framework Appreciative Inquiry

approach Stimulate dialogue Promote learning Shared understanding Safety Differently language

Presenter

Presentation Notes

Take Away Messages• Prevention - wise investment,

but it is not enough

• We must be able to respond when things go badly (because they will)

• Feedback loops can improve safety, efficiency and outcomes

• Learning from what is working well (and not so well) is a super power

• People are not the problem. They are the solution.


Bonus….Sidebar

Conklin’s 3 questions

1. When you do this job, what will kill or hurt you?

2. When that happens, (not if, but when)… what keeps you from dying?

3. Is that enough?


Presenter

Presentation Notes

Relationship of this to our risk assessment processes.


RISK RATING MATRIX

CONSEQUENCE

LIKELIHOOD Insignificant Minor Moderate Major Catastrophic

Almost Certain Mod Mod High Ext Ext

Likely Low Mod High Ext Ext

Possible Low Low Mod High Ext

Unlikely Low Low Mod High High

Rare Low Low Low Mod High

Presenter

Presentation Notes

Do you love the matrix?


Sid

ebar

Presenter

Presentation Notes

Partial list of consequence scale.


STEP 2. STEP 3. STEP 4a.

STEP 4b.

STEP 4c.

STEP 5. STEP 6a.

STEP 6b.

STEP 6c.

STEP 7.

Ref No.

SPECIFIC ACTIVITY STEPS IDENTIFY POTENTIAL HAZARDS

INHERENT RISK RISK CONTROL MEASURES

• Hierarchy of Control –Elimination, Substitution,Isolation, Engineering,Administration, PersonalProtection.

• Additional information can be attached.

RESIDUAL RISK

Actio

ner /

Initi

als

Cons

eque

nce

Like

lihoo

d

Risk

Rat

ing

Cons

eque

nce

Like

lihoo

d

Risk

Rat

ing

Bonus….Sidebar

Conklin’s 3 questions

1. When you do this job, what will kill or hurt you?

2. When that happens, (not if, but when)… what keeps you from dying?

3. Is that enough?


Presenter

Presentation Notes

Idea of blending this with our model and the AI and LR approach to create a better Risk Assessment model

AcknowledgementsSidney Dekker PhD. Professor

Safety Science Innovation LabGriffith University, Nathan, QLDProfessor, Delft University, the Netherlands

Ivan Pupulidy PhD. Adjunct Professor Advanced Safety Engineering and Management University of Alabama at BirminghamSanta Fe, NM

Crista Vesel MSc. Dynamic Inquiry LLC ‘All change starts with a question’


References• Conklin, T. (2012). Pre-Accident Investigations: an

introduction to organizational safety. CRC Press.• Dekker, S. (2006). The field guide to understanding

human error. Burlington, Vermont: Ashgate Publishing Company.

• Dekker, S. (2015). Safety Differently: human factors for a new era. 2nd ed. CRC Press.

• Dekker, S. (2019). Foundations of safety science: a century of understanding accidents and disasters. Routledge.

• Hodges, V. (2007) When Everything Goes Right: Implications for Scientific Diving Safety Programs. In: Pollock and Godfrey (Eds.) The Diving for Science 2007, Proceedings of the American Academy of Underwater Sciences (AAUS).

• Lock, G. DEBRIEF Model, Human in the System• Pupulidy, I., and Vesel, C. (2017). The Learning Review:

Adding to the accident investigation toolbox. Proceedings of the 53rd ESReDA Seminar, Ispar, Italy, 14-15 November 2017. European Commission Joint Research Centre.

• Vesel, C. (2012). Language bias in accident investigation. Master of Science Degree Dissertation. Sweden: Lund University.


Questions? Feedback?

Vallorie HodgesSafety & Wellbeing Advisor/University Dive Officer

University of Tasmania

Private Bag 46, Hobart, TAS 7001

Ph: 03 6226 7200 mobile: 0400 479 140

[email protected]

Fiona McCarthy(OT) M.Bieth (Monash) M Ergonomics

Safety and Health (Latrobe)

Australian Institute of Health and Safety (COHS Prof)

Full member HFESA

[email protected]


mailto:[email protected]

mailto:[email protected]

Parting Shot - don’t forget to look behind you!

Hawaiian Monk seal watches divers

Image courtesy of David CutterHodges & McCarthy, University of Tasmania July 2021

prevention is not enough

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