Incident Reporting & Data Analytics: Implementing a Risk Management Information System for Youth Protection Workshop at the HEPNet 2020 Conference
Managing risk in youth programming means understanding the factors that either lead to incident events or to safe programming. Your best defense against risk is data collection and analysis of incidents and close calls to be able to quickly identify and mitigate hazards.
In this workshop we’ll start by exploring the traditional Safety I approach to risk management which focuses on what went wrong and takes a ‘control mistakes’ approach to identify weaknesses or failures in the system. Safety I is often used as a framework for post-incident review to identify and address the contributing factors that led to the event. This is a critical risk management step after any serious incident.
While post-incident analysis is critical, far more of our programming is safe and successful. The Safety II framework looks proactively at those factors which create success and work to ensure that those are present in all programming. Any comprehensive risk management approach requires using both Safety I and Safety II frameworks.
The Systems Theory approach to risk management (Rasmussen, 1997) allows us to combine the Safety I Safety II frameworks to create a comprehensive risk management approach. Rasmussen identified that accidents are not the result of a failure at a single point, but that any failure point is related to multiple other aspects of the entire system. Government, regulatory agencies, organizations, parents, providers, staff, participants, work setting, etc. all interact to create either safe or unsafe environments. Managing safety means understanding the relationships between factors at each level and determining the most effective methods of intervention.
The essential element in implementing a Systems Approach to Safety I & Safety II is data collection. Information on incidents and close calls must be collected in a consistent manner to allow organizations to identify trends both in the hazards contributing to incident events and the mitigating factors that create safe and successful programming. A Risk Management Information System (RMIS) provides a structured data collection and analysis for both Safety I and Safety II frameworks. We will use the IncidentAnalytix data collection and analysis system as a sample RMIS for analyzing your program through both a Safety I and a Safety II lens.
How to build an AcciMap
- Create a blank AcciMap with the Taxonomy headings on the left sidebar in hierarchical order
- Identify the outcome(s) and enter at the bottom
- Identify Causal Factors on a sticky note
- Enter the Causal Factors at each Taxonomy Level
- Identify the Relationships between Factors
- Had A not occurred, B would (probably) not have occurred
- B is a direct result of A (no other factor in between, otherwise link A to C and C to B)
- Check causal logic
- What is In Scope?
- What is Out of Scope
- Create an Action Plan based on what is In Scope
Resources from the Workshop:
- PowerPoint PDF of Workshop
- Sample AcciMap/PreventiMap Template PDF
- Risk Management in a Dynamic Society: A modeling problem – Jens Rasmussen (1997)
- From Safety-I to Safety-II: A White Paper – Hollnagel E; Wears RL; Braithwaite J. (2015)
- 1.5.5 Safety I vs Safety II – https://www.youtube.com/watch?v=WM0LVv9NrhM
- Doing Safety Differently – Sydney Dekker: https://www.youtube.com/watch?v=6gREMV6j2A4
- Safety II & Safety II – Erik Hoffnagel: https://vimeo.com/channels/1366431/89492241
- Perceiving what cannot be seen” ‐ the practical side of Safety ‐ II – Erik Hollnagel: https://vimeo.com/159498494
- A story of Safety II – Jeffrey Braithwaite: https://www.youtube.com/watch?v=gauR843rRNk
- Safety Differently | The Movie: https://www.youtube.com/watch?v=moh4QN4IAPg
- Sidney Dekker — Safety Differently Lecture: https://www.youtube.com/watch?v=oMtLS0FNDZs
- Sidney Dekker — Just Culture short course 1: https://www.youtube.com/watch?v=PVWjgqDANWA
- The New View of Safety with Todd Conklin: https://www.youtube.com/watch?v=IoYUQlWiRgc
- Dr. Todd Conklin speech “Risk Analysis is Fixed in Time – But Hazards Ebb and Flow: https://www.youtube.com/watch?v=X211fU39808
- Guidelines for AcciMap Analysis: https://openresearch-repository.anu.edu.au/bitstream/1885/20987/2/01_Branford_Guidelines_for_ACCIMAP_2009.pdf
- Webinar: An Introduction to “New Safety” (HOP, Safety II, and Safety Differently): https://www.youtube.com/watch?v=zqZVGaFIhyw
- FAA Safety Management Systems (SMS) Fundamentals: Policy: https://www.youtube.com/watch?v=j8N0PZx5YwM
- FAA Safety Management Systems (SMS) Fundamentals: Safety Risk Management Component: https://www.youtube.com/watch?v=b6dwxQ3oEAE
- Mangatepopo canyoning tragedy a decade on: ‘I know they would be loving every minute of life’: https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12032068
- In a Flash TV Movie: https://www.tvnz.co.nz/shows/in-a-flash/episodes/s1-e1
- BBC NASA Challenger Disaster: https://www.youtube.com/watch?v=reM5fTo-6PI
- Challenger Disaster Governmental Report: https://www.govinfo.gov/content/pkg/GPO-CRPT-99hrpt1016/pdf/GPO-CRPT-99hrpt1016.pdf
- A Review of Accident Modelling Approaches for Complex Critical Sociotechnical Systems: https://www.semanticscholar.org/paper/A-Review-of-Accident-Modelling-Approaches-for-Qureshi/c3a597212068c27be45d84dec76e86baabd4cf90