Rasmussen's legacy in the great outdoors: A new incident reporting and learning system for led outdoor activities

Research on the development relationship between safety production indicators and economic and social indicators in China

In order to study the relationship between China's safety production indicators and economic and social indicators, the development trend of indicator data in the past 20 years was statistically analyzed, and qualitative and quantitative research was conducted using grey relational analysis and multiple linear regression analysis methods. In the past two decades, there has been a significant improvement in the number of deaths, work-related injuries, and occupational patients in China's safety production, and the country's three categories of 14 economic and social indicators have achieved rapid development. Using the grey relation analysis method, the grey correlation degree between the number of deaths, work-related injuries, and occupational patients in China over the past twenty years and 14 economic and social indicators was obtained. The ranking of economic and social indicators that affect the number of deaths, work-related injuries, and occupational patients varies greatly. A multiple linear regression model was established for the number of deaths, work-related injuries, occupational diseases, and 14 economic and social indicators. The rationality of the model was verified from four aspects: R2, F-value, P-value, and deviation between actual and fitted values. Provide guidance for the development of safety production indicators and economic and social indicators in China through research.

The application of systematic accident analysis tools to investigate food safety incidents

Effective food safety (FS) management relies on the understanding of the factors that contribute to FS incidents (FSIs) and the means for their mitigation and control. This review aims to explore the application of systematic accident analysis tools to both design FS management systems (FSMSs) as well as to investigate FSI to identify contributive and causative factors associated with FSI and the means for their elimination or control. The study has compared and contrasted the diverse characteristics of linear, epidemiological, and systematic accident analysis tools and hazard analysis critical control point (HACCP) and the types and depth of qualitative and quantitative analysis they promote. Systematic accident analysis tools, such as the Accident Map Model, the Functional Resonance Accident Model, or the Systems Theoretical Accident Model and Processes, are flexible systematic approaches to analyzing FSI within a socio-technical food system which is complex and continually evolving. They can be applied at organizational, supply chain, or wider food system levels. As with the application of HACCP principles, the process is time-consuming and requires skilled users to achieve the level of systematic analysis required to ensure effective validation and verification of FSMS and revalidation and reverification following an FSI. Effective revalidation and reverification are essential to prevent recurrent FSI and to inform new practices and processes for emergent FS concerns and the means for their control.

Testing the reliability of accident analysis methods: a comparison of AcciMap, STAMP-CAST and AcciNet

Accident analysis methods are used to model the multifactorial cause of adverse incidents. Methods such as AcciMap, STAMP-CAST and recently AcciNet, are systemic approaches that support the identification of safety interventions across sociotechnical system levels. Despite their growing popularity, little is known about how reliable systems-based methods are when used to describe, model and classify contributory factors and relationships. Here, we conducted an intra-rater and inter-rater reliability assessment of AcciMap, STAMP-CAST and AcciNet using the Signal Detection Theory (SDT) paradigm. A total of 180 hours' worth of analyses across 360 comparisons were performed by 30 expert analysts. Findings revealed that all three methods produced a weak to moderate positive correlation coefficient, however the inter-rater reliability of STAMP-CAST was significantly higher compared to AcciMap and AcciNet. No statistically significant or practically meaningful differences were found between methods in the overall intra-rater reliability analyses. Implications and future research directions are discussed.

What Enables Child Sexual Abuse in Sport? A Systematic Review

Sporting environments provide opportunities for perpetrators to commit child sexual abuse (CSA). While awareness of CSA in sport and preventative interventions are increasing, CSA in sport still occurs at alarming rates. A systematic review was conducted to identify and synthesize the extant literature on the enabling factors for CSA in sport. The 34 included articles were peer-reviewed and were primary sources; had full-text versions in English; included the individual, situational, environmental, or systemic antecedent factors and characteristics which enable CSA in organized sport (clubs, schools, universities, and representative teams); and focused on abuse in children (0-18 years old), and included retrospective incidents. The enabling factors from across the broader sports system were identified and mapped using a systems thinking-based approach, the Risk Management Framework (RMF) and the associated AcciMap method. The results indicated that enabling factors for CSA in sport were identified at multiple levels of the sporting system hierarchy. The results show that 24.1% (n = 46) of the enabling factors identified in the literature relate to the hierarchical level of the Athlete, teammates, opponents, and fans levels, and 52.9% (n = 101) of the enabling factors relate to the level of Direct supervisors, management, medical, and performance personnel level. However, only 13% (n = 25) of enabling factors to CSA in sport were identified at the combined top four hierarchical levels. Results indicate that the problem of CSA in sport is a systems issue, and future research is required to explore how these factors interact to enable CSA in sport.

Applying a systems thinking lens to anti-doping: A systematic review identifying the contributory factors to doping in sport

The use of performance enhancing substances and methods (known as "doping") in sport is an intractable issue, with current anti-doping strategies predominantly focused on the personal responsibility and strict liability of individual athletes. This is despite an emerging understanding that athletes exist as part of a broader complex sports system that includes governance, policymakers, media, sponsors, clubs, team members, and athlete support staff, to name a few. As such, there is a need to examine the broader systemic factors that influence doping in sport. The aim of this systematic review was to identify and synthesise the factors contributing to doping and doping behaviours, attitudes, and beliefs and the extent to which this knowledge extends beyond the athlete to consider broader sports systems. The review followed PRISMA guidelines with risk of bias and study quality assessed by the Mixed Methods Appraisal Tool, and identified contributory factors synthesised and mapped onto a systems thinking-based framework. Overall, the included studies were determined to be of high quality. Support personnel, the coach, and the coach-athlete relationship represent key influences on the athletes' decisions to dope. From the evidence presented, doping is an emergent property of sport systems and represents a complex systemic problem that will require whole-of-system interventions. The implications for this and the focus of future research are discussed.

Quest for clarity: investigating concussion-related responsibilities across the New Zealand Rugby Community System

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand's community rugby system's perceptions of their own and others' concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players' welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A 'framework of responsibilities' may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders.

Using systems thinking-based risk assessment methods to assess hazardous manual tasks: a comparison of Net-HARMS, EAST-BL, FRAM and STPA

Formal risk assessment is a component of safety management relating to hazardous manual tasks (HMT). Systems thinking approaches are currently gaining interest for supporting safety management. Existing HMT risk assessment methods have been found to be limited in their ability to identify risks across the whole work system; however, systems thinking-based risk assessment (STBRA) methods were not designed for the HMT context and have not been tested in this area. The aim of this study was to compare the performance of four state-of-the-art STBRA methods: Net-HARMS, EAST-BL, FRAM and STPA to determine which would be most useful for identifying HMT risks. Each method was independently applied by one of four analysts to assess the risks associated with a hypothetical HMT system. The outcomes were assessed for alignment with a benchmark analysis. Using signal detection theory (SDT), overall STPA was found to be the best performing method having the highest hit rate, second lowest false alarm rate and highest Matthews Correlation Coefficient of the four methods.Practitioner summary: A comparison of four systems thinking risk assessment methods found that STPA had the highest level of agreement with the benchmark analysis and is the most suitable for practitioners to use to identify the risks associated with HMT systems.

Incident reporting in the outdoors: a systems-based analysis of injury, illness, and psychosocial incidents in led outdoor activities in Australia

Incident reporting systems are a fundamental component of safety management, however, most systems used in practice are not aligned with contemporary accident causation models. This article presents an analysis of a National Incident Dataset (NID) for adverse incidents occurring in the Australian Led Outdoor Activity (LOA) sector. The aim was to investigate the adverse Injury, Illness, and Psychosocial incidents reported to the NID. In total, 1657 injuries, 532 illnesses, and 146 psychosocial incidents were analysed from 357,691 program participation days. The findings show that the rate of incidents per 1000 program participant days in LOAs was 4.6 for injury, 1.5 for illness, and 0.04 for psychosocial incidents, and incident severity was predominately minor. The analysis of systemic contributory factors demonstrates that incidents in LOA are systemic in nature, with multiple levels of the LOA system identified as contributing to adverse incidents. For example, contributory factors were identified across local government (facilities), schools (communication), parents (communication), LOA management (policies and procedures), people involved in the incidents (mental and physical condition), and the environment (terrain) and equipment (clothing). This study presents an assessment of the current state of safety in the Australian LOA sector and demonstrates the utility of applying systems ergonomics methods in practice. Practitioner summary: This article presents an analysis of 1657 injury, 532 illness, and 146 psychosocial incidents occurring in the Australian Led Outdoor Activity (LOA) sector, using a systems ergonomics method. The findings demonstrate the incident charactersitics and how decisions and actions from across the system contribute to adverse incidents in LOAs.

Systems Thinking Accident Analysis Models: A Systematic Review for Sustainable Safety Management

Accident models are mental models that make it possible to understand the causality of adverse events. This research was conducted based on five major objectives: (i) to systematically review the relevant literature about AcciMap, STAMP, and FRAM models and synthesize the theoretical and experimental findings, as well as the main research flows; (ii) to examine the standalone and hybrid applications for modeling the leading factors of the accident and the behavior of sociotechnical systems; (iii) to highlight the strengths and weaknesses of exploring the research opportunities; (iv) to describe the safety and accident models in terms of safety-I-II-III; and finally, to investigate the impact of the systemic models’ applications in enhancing the system’s sustainability. The systematic models can identify contributory factors, functions, and relationships in different system levels which helps to increase the awareness of systems and enhance the sustainability of safety management. Furthermore, their hybrid extensions can significantly overcome the limitations of these models and provide more reliable information. Applying the safety II and III concepts and their approaches in the system can also progress their safety levels. Finally, the ethical control of sophisticated systems suggests that further research utilizing these methodologies should be conducted to enhance system analysis and safety evaluations.

Evaluation of a systems ergonomics-based incident reporting system

INTRODUCTION

Incident reporting and learning systems are a fundamental component of safety management. The purpose of this study was to evaluate a novel incident reporting system specific to the Australian Led Outdoor Activity (LOA) sector. The Understanding and Preventing Led Outdoor Accidents Data System (UPLOADS), is a recently introduced systems thinking-based incident reporting and learning system that utilises contemporary safety theory and methods.

METHOD

The implementation of UPLOADS was evaluated using the RE-AIM framework based on the following dimensions: Reach, Efficacy, Adoption, Implementation, and Maintenance. A pragmatic evaluation approach was used in which evaluation data were collected through the triangulation of multiple sources including different LOA stakeholders from both the individual organisational level (LOA providers) and LOA sector governance level (LOA industry representatives), incident data collected through the UPLOADS National Incident Dataset, and the online and physical presence of UPLOADS.

RESULTS

The findings show that a key strength of UPLOADS is its effectiveness as incident reporting tool for improving safety in the LOA sector. However, a weakness of UPLOADS is that it is not being implemented appropriately by the LOA providers.

CONCLUSION

Overall, the current findings suggest that UPLOADS incident reporting tool is perceived by SMEs as an effective tool for improving safety in LOA. However, further work is required for UPLOADS to have a greater impact on the LOA sector. Specifically, Implementation of the UPLOADS system requires improvement, as well as additional training and education may be required to upskill and empower LOA providers to improve reporting and enhance the value placed on safety by LOA stakeholders. The RE-AIM framework was an appropriate evaluation framework for understanding the effectiveness of UPLOADS as a LOA sector specific incident reporting and learning system.

PRACTICAL APPLICATIONS

The current findings have practical implications for ergonomics researchers applying evaluation frameworks in the real world, and LOA providers for implementing safety interventions. Lastly, contemporary systems-based incident reporting and learning systems have the capability to enhance the safety practices of the LOA sector.

Taking a mixed-methods approach to collision investigation: AcciMap, STAMP-CAST and PCM

Recently, ergonomics and safety researchers have turned their attention towards applying combinations of sociotechnical methods rather than using single methods in isolation. In the current research, a mixed-method approach combining two systems-based methods, Accimaps and the Systems Theoretic Accident Model and Process - Causal Analysis using Systems Theory (STAMP-CAST), and one cognitive approach, the Perceptual Cycle Model (PCM), were employed in analysing a rail-level crossing incident in Bangladesh. Each method was applied individually to investigate the collision, and interventions were proposed corresponding to incident events at different risk management framework levels. The three methods provided different perspectives of the whole picture, together identifying an array of contributory factors. The complementary nature of these methods aided in proposing a comprehensive set of safety recommendations, thereby demonstrating the benefit of a mixed-method approach for collision investigation in low-income settings.

Complexity theory in accident causation: using AcciMap to identify the systems thinking tenets in 11 catastrophes

The quest to explain and understand the cause of accidents is both ever-present and ongoing amongst the safety science community. In an attempt to advance the theory and science of accident causation, researchers have recently formalised a set of '15 systems thinking tenets' that cover the conditions and characteristics of work systems that are believed to contribute to the cause of accidents. The purpose of this study was to attempt to identify the systems thinking tenets across a range of different systems and accidents using the Accident Mapping (AcciMap) method. The findings suggest that the tenets can be attributed to play a role in accident causation, however as a result of this process, the capability of AcciMap has been brought into question. Implications and directions for future research are described. Practitioner Summary: This study is an extension of previous work that suggested there was a need to test for the 'systems thinking tenets of accident causation' in a multi-incident dataset. We used AcciMap to evaluate whether it has the capability to support ongoing accident analysis activities in ergonomics research.

Applying AcciMap to test the common cause hypothesis using aviation near misses

The common cause hypothesis, as applied here, proposes that similar networks of influencing factors may contribute to both adverse outcomes and near misses. This hypothesis has not been evaluated using a systems-thinking perspective. The aims of this study are to evaluate whether networks of contributory and protective factors exist within aviation serious near miss reports and to determine if the common cause hypothesis is applicable in this context. Sixteen incident reports from French civil aviation crash investigation bureau were analysed using the AcciMap method. Contributory and protective factors, and relationships between both were identified via coding of the reports. The results indicate that considering protective factors support a richer picture of incidents and provide support for the common cause hypothesis as measured by similar mean factor volume and sociotechnical levels for both contributory and protective factors. However, the findings also show the direction of relationships among protective and contributory factors may be indicative of a difference among adverse outcomes, near misses, and normal work. Future research should consider how a network of relationships may impact on the common contributory and protective factors found in near misses.

Evaluation of construct and criterion-referenced validity of a systems-thinking based near miss reporting form

The validity of methods is an ongoing issue in ergonomics. Inconsistent definitions and approaches to evaluation exacerbate this challenge. In this study, the construct and criterion-referenced validity of a new near miss reporting form was evaluated to determine the extent to which it comprehensively captures near miss incidents and is aligned with the systems thinking approach to accident causation. Interview data were used as the reference standard in the evaluation. Using signal detection theory (SDT), a high average hit rate (HR), predictive value (PV) and sensitivity index (SI) were found, with an almost perfect ranking for the index of concordance. The findings show that the reporting form has strong construct and criterion-referenced validity. It is proposed that the approach used in this study could be used by researchers and practitioners when testing the validity of incident data collection tools. Practitioner summary: The validity of methods is a key issue in ergonomics. In this study, we test the validity of a near miss reporting form using interview data as a standard. This approach could be used by practitioners when testing the validity of other ergonomics methods.

Applying a systems thinking lens to injury causation in the outdoors: Evidence collected during 3 years of the Understanding and Preventing Led Outdoor Accidents Data System

Introduction

This article presents a detailed systems analysis of injury incidents from 35 Australian led outdoor activity organisations between 2014 to 2017.

Method

Injury incident reports were collected using a specific led outdoor activity incident reporting system known as UPLOADS (Understanding and Preventing Led Outdoor Accidents Data System).

Results

In total, 1367 people sustained injuries from across 20 different activities, with an injury rate of 1.9 injured people per 1000 participants over the three-year period. A total of 2234 contributory factors from multiple levels of the led outdoor activity system were identified from the incident reports, and 361 relationships were identified between contributory factors.

Discussion

This systems analysis of injury incidents demonstrates that it is not only factors within the immediate context of the incident (Participants, Environment, Equipment) but factors from across multiple systemic levels that contributes to injury incidents (Schools, Parents, Activity centre management). Prevention efforts should focus on addressing the whole network of contributing factors and not only the prominent factors at the lower system levels within the immediate context of the injury incident occurrences.

Applying systems ergonomics methods in sport: A systematic review

INTRODUCTION

As sports systems become increasingly more complex, competitive, and technology-centric, there is a greater need for systems ergonomics methods to consider the performance, health, and safety of athletes in context with the wider settings in which they operate. Therefore, the purpose of this systematic review was to identify and critically evaluate studies which have applied a systems ergonomics research approach in the context of sports performance and injury management.

MATERIAL AND METHODS

Five databases (PubMed, Scopus, ScienceDirect, Web of Science, and SPORTDiscus) were searched for the dates 01 January 1990 to 01 August 2017, inclusive, for original peer-reviewed journal articles and conference papers. Reported analyses were underpinned by a recognised systems ergonomics method, and study aims were related to the optimisation of sports performance (e.g. communication, playing style, technique, tactics, or equipment), and/or the management of sports injury (i.e. identification, prevention, or treatment).

RESULTS

A total of seven articles were identified. Two articles were focussed on understanding and optimising sports performance, whereas five examined sports injury management. The methods used were the Event Analysis of Systemic Teamwork, Cognitive Work Analysis (the Work Domain Analysis Abstraction Hierarchy), Rasmussen's Risk Management Framework, and the Systems Theoretic Accident Model and Processes method. The individual sport application was distance running, whereas the team sports contexts examined were cycling, football, Australian Football League, and rugby union.

CONCLUSIONS

The included systems ergonomics applications were highly flexible, covering both amateur and elite sports contexts. The studies were rated as valuable, providing descriptions of injury controls and causation, the factors influencing injury management, the allocation of responsibilities for injury prevention, as well as the factors and their interactions underpinning sports performance. Implications and future directions for research are described.

End-user experiences with two incident and injury reporting systems designed for led outdoor activities - challenges for implementation of future data systems

Background

Injury and incident (near miss) prevention is heavily dependent upon robust and high-quality data systems. Evaluations of surveillance systems designed to report factors associated with incidents and injuries are essential to understand their value, as well as to improve their performance and efficiency. Despite, this there have been few such evaluations published in the peer-review literature.

Methods

The attitudes and experiences of industry representatives who used one of two variants of an incident and injury surveillance system to collect injury and incident data for the led outdoor activity setting were obtained through an online self-report survey following a 12-month trial. Survey respondents were 18 representatives of 33 organisations who were users of a comprehensive incident reporting and surveillance system – the Understanding and Preventing Led Outdoor Accidents Data System Software Tool (UPLOADS-ST) - and six out of 11 users of a modified system (UPLOADS-Lite). The survey collected information on user experiences in relation to system training, accessibility, ease of use, security, feedback and perceived value to the sector of collating and reporting data across organisations.

Findings

Only four UPLOADS-ST responding users found the system easy to use and just three considered entering incident reports to be easy. However, many considered the training on reporting incidents to be sufficient and that the incident reports contained relevant details. Fewer than half of respondents (seven for UPLOADS-ST, three for UPLOADS-Lite) believed entering data was a good use of staff time and resources. Nonetheless, a majority of respondents (seven for UPLOADS-ST, five for UPLOADS-Lite) found the reporting format easy to read and felt the information provided was useful for their organisation.

Conclusions

Usability barriers to incident reporting were identified, particularly for UPLOADS-ST, including time constraints and user friendliness. The majority of users believed aggregating and reporting incident and injury data across organisations would be of value in making the led outdoor activity sector safer. Improving the utility of the surveillance systems will assist in ensuring their sustainability in the led outdoor activity sector.

To Computerised Provider Order Entry system: A comparison of ECF, HFACS, STAMP and AcciMap approaches

Different accident analytical approaches have been utilised in safety-critical industries for analysing accidents and formulating safety recommendations. This study presents a 'health informatics' case incident of a patient adversely affected due to a medication dosing error resulting from a combination of contributing factors including those relating to the Computerised Order Provider Entry System. A comparative study was carried out using selected accident analytical approaches: Human Factors and Classification System, System-Theoretic Accident Modelling and Processes and Accident Modelling. Each resulting output was compared using the model characteristic criteria developed by Underwood and Waterson. Safety recommendations developed based on the outputs from the models/methods were also compared for any similar findings. It was acknowledged that while accident models incorporating 'systems thinking' can prove to be beneficial for healthcare in providing insight on systemic factors, there is a need for improving the reliability and validity of these models. This particularly applies to Rasmussen's Accident Modelling approach to be considered useful in the healthcare domain.

Many model thinking in systems ergonomics: a case study in road safety

In complexity science, the many models thinking philosophy argues for a multi-method approach to complex problems. This article investigates whether the use of multiple systems ergonomics methods to examine the same problem is useful, or whether using different approaches creates incompatible analyses. Five systems ergonomics analyses of road trauma are examined and their key insights extracted. The extent to which these insights are compatible with one another and can be integrated when attempting to reduce road trauma is assessed. The findings indicate that applying several systems ergonomics methods to the same problem is useful, as multiple insights are developed and deficiencies in one approach are countered by the others. Importantly, the case study demonstrates that the insights gained are compatible and support the development of holistic systems thinking-based interventions. In conclusion it is recommended that a many systems ergonomics model thinking approach be adopted by ergonomists working in complex problem spaces. Practitioner Summary: Many model thinking uses multiple methods to understand complex problems. We explore whether this is beneficial in systems ergonomics. Five models of road trauma, developed using five systems ergonomics methods, are examined. The findings demonstrate that a many model systems ergonomics approach produces a diverse but complimentary set of insights.

Bad behaviour or societal failure? Perceptions of the factors contributing to drivers' engagement in the fatal five driving behaviours

The so-called 'fatal five' behaviours (drink and drug driving, distraction and inattention, speeding, fatigue, and failure to wear a seat belt) are known to be the major behavioural contributory factors to road trauma. However, little is known about the factors that lead to drivers engaging in each behaviour. This article presents the findings from a study which collected and analysed data on the factors that lead to drivers engaging in each behaviour. The study involved a survey of drivers' perceptions of the causes of each behaviour and a subject matter expert workshop to gain the views of road safety experts. The results were mapped onto a systems ergonomics model of the road transport system in Queensland, Australia, to show where in the system the factors reside. In addition to well-known factors relating to drivers' knowledge, experience and personality, additional factors at the higher levels of the road transport system related to road safety policy, transport system design, road rules and regulations, and societal issues were identified. It is concluded that the fatal five behaviours have a web of interacting contributory factors underpinning them and are systems problems rather than driver-centric problems. The implications for road safety interventions are discussed.

Developing a contributing factor classification scheme for Rasmussen's AcciMap: Reliability and validity evaluation

One factor potentially limiting the uptake of Rasmussen's (1997) Accimap method by practitioners is the lack of a contributing factor classification scheme to guide accident analyses. This article evaluates the intra- and inter-rater reliability and criterion-referenced validity of a classification scheme developed to support the use of Accimap by led outdoor activity (LOA) practitioners. The classification scheme has two levels: the system level describes the actors, artefacts and activity context in terms of 14 codes; the descriptor level breaks the system level codes down into 107 specific contributing factors. The study involved 11 LOA practitioners using the scheme on two separate occasions to code a pre-determined list of contributing factors identified from four incident reports. Criterion-referenced validity was assessed by comparing the codes selected by LOA practitioners to those selected by the method creators. Mean intra-rater reliability scores at the system (M = 83.6%) and descriptor (M = 74%) levels were acceptable. Mean inter-rater reliability scores were not consistently acceptable for both coding attempts at the system level (M_T1 = 68.8%; M_T2 = 73.9%), and were poor at the descriptor level (M_T1 = 58.5%; M_T2 = 64.1%). Mean criterion referenced validity scores at the system level were acceptable (M_T1 = 73.9%; M_T2 = 75.3%). However, they were not consistently acceptable at the descriptor level (M_T1 = 67.6%; M_T2 = 70.8%). Overall, the results indicate that the classification scheme does not currently satisfy reliability and validity requirements, and that further work is required. The implications for the design and development of contributing factors classification schemes are discussed.

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

Application of Human Factors Analysis and Classification System (HFACS) to UK rail safety of the line incidents

Minor safety incidents on the railway cause disruption, and may be indicators of more serious safety risks. The following paper aimed to gain an understanding of the relationship between active and latent factors, and particular causal paths for these types of incidents by using the Human Factors Analysis and Classification System (HFACS) to examine rail industry incident reports investigating such events. 78 reports across 5 types of incident were reviewed by two authors and cross-referenced for interrater reliability using the index of concordance. The results indicate that the reports were strongly focused on active failures, particularly those associated with work-related distraction and environmental factors. Few latent factors were presented in the reports. Different causal pathways emerged for memory failures for events such a failure to call at stations, and attentional failures which were more often associated with signals passed at danger. The study highlights a need for the rail industry to look more closely at latent factors at the supervisory and organisational levels when investigating minor safety of the line incidents. The results also strongly suggest the importance of a new factor - operational environment - that captures unexpected and non-routine operating conditions which have a risk of distracting the driver. Finally, the study provides further demonstration of the utility of HFACS to the rail industry, and of the usefulness of the index of concordance measure of interrater reliability.