Margaret J. Trotter

A systems approach to accident causation in mining: An application of the HFACS method

This project aimed to provide a greater understanding of the systemic factors involved in mining accidents, and to examine those organisational and supervisory failures that are predictive of sub-standard performance at operator level. A sample of 263 significant mining incidents in Australia across 2007-2008 were analysed using the Human Factors Analysis and Classification System (HFACS). Two human factors specialists independently undertook the analysis. Incidents occurred more frequently in operations concerning the use of surface mobile equipment (38%) and working at heights (21%), however injury was more frequently associated with electrical operations and vehicles and machinery. Several HFACS categories appeared frequently: skill-based errors (64%) and violations (57%), issues with the physical environment (56%), and organisational processes (65%). Focussing on the overall system, several factors were found to predict the presence of failures in other parts of the system, including planned inappropriate operations and team resource management; inadequate supervision and team resource management; and organisational climate and inadequate supervision. It is recommended that these associations deserve greater attention in future attempts to develop accident countermeasures, although other significant associations should not be ignored. In accordance with findings from previous HFACS-based analyses of aviation and medical incidents, efforts to reduce the frequency of unsafe acts or operations should be directed to a few critical HFACS categories at the higher levels: organisational climate, planned inadequate operations, and inadequate supervision. While remedial strategies are proposed it is important that future efforts evaluate the utility of the measures proposed in studies of system safety.

Effects on driving performance of interacting with an in-vehicle music player: A comparison of three interface layout concepts for information presentation

Interface design is an important factor in assessing the potential effects on safety of interacting with an in-vehicle information system while driving. In the current study, the layout of information on a visual display was manipulated to explore its effect on driving performance in the context of music selection. The comparative effects of an auditory-verbal (cognitive) task were also explored. The driving performance of 30 participants was assessed under both baseline and dual task conditions using the Lane Change Test. Concurrent completion of the music selection task with driving resulted in significant impairment to lateral driving performance (mean lane deviation and percentage of correct lane changes) relative to the baseline, and significantly greater mean lane deviation relative to the combined driving and the cognitive task condition. The magnitude of these effects on driving performance was independent of layout concept, although significant differences in subjective workload estimates and performance on the music selection task across layout concepts highlights that potential uncertainty regarding design use as conveyed through layout concept could be disadvantageous. The implications of these results for interface design and safety are discussed.

Improvisation: theory, measures and known influencing factors

Interest in the potential of improvisation to enhance safety outcomes in safety critical situations has been increasing; however, improvisation also has the potential to make emergency situations worse rather than better. If organisations are to capitalise on improvisations potential to produce safety benefits, a model of the factors that influence its effectiveness in safety critical situations is needed. This review draws together what is currently known about the factors influencing improvisation and the methods used to examine them. The review reveals that, unlike most contemporary ergonomics concepts, as yet no research has examined factors beyond organisational boundaries or examined the interactions of factors across different systems levels, both integral components of systems-based models. In closing, discussion is presented on the most appropriate research agenda for enhancing understanding of improvisation and its influencing factors.

Key Factors Influencing Implementation of Falls Prevention Exercise Programs in the Community

The study aim was to evaluate the implementation of group- and home-based exercise falls prevention programs delivered through community health agencies to community-dwelling older people. Interviews with program staff were guided by the Diffusion of Innovations theory. Highly consistent themes emerged for the two types of programs. Both had high overall compatibility, high relative advantage, good observability and high inherent trialability--all factors known to strengthen implementation. The level of complexity and low financial compatibility emerged as the strongest potential inhibitors to program implementation in the context examined. The two main factors contributing to complexity were the need to challenge balance safely across a broad range of capability, and practical considerations associated with program delivery. A range of strategies to provide more technical support for exercise program leaders to tailor balance challenge for exercise program leaders may enhance implementation of falls prevention exercise programs.

Distributed improvisation: a systems perspective of improvisation ‘epics’ by led outdoor activity leaders

Abstract Improvisation represents the spontaneous and real-time conception and execution of a novel response to an unanticipated situation. In order to benefit from the positive safety potential of this phenomenon, it is necessary to understand what influences its appropriateness and effectiveness. This study has applied the system-based methodology Impromaps to analysing accounts of improvisation aimed at mitigating adverse safety outcomes. These accounts were obtained from led outdoor activity (LOA) leaders through critical decision method interviews. Influencing factors and interactions have been identified across all system levels. The factors most influential to leaders’ ability to improvise are ‘Policy, procedures and rules’, ‘Organisation culture’, ‘Training’, ‘Role responsibilities’, ‘Communication/instruction/demonstration’, ‘Situation awareness’, ‘Leader experience’, ‘Mental simulation’, ‘Equipment, clothing & PPE’ and ‘Terrain/physical environment’. To enhance the likelihood of effective, appropriate improvisation, LOA providers are recommended to focus on higher level factors over which they are able to exert greater control. Practitioner Summary: To enhance resilience in safety-critical situations, organisations need to understand what influences appropriate, effective improvisation. To elucidate this, the Impromaps methodology is applied to in-depth interview data. The Impromap affords a graphical depiction of the influencing factors and interactions across the system, providing a basis for the development of interventions.

Implementation of evidence‐based falls prevention in clinical services for high‐risk clients

RATIONALE, AIMS AND OBJECTIVES The extent to which best practice for falls prevention is being routinely delivered by health care providers for community-dwelling older adults is unclear. We investigated falls prevention practice among Hospital Admission Risk Programs (HARP) that provide and coordinate specialized health care for people at high risk of hospitalization. METHOD Cross-sectional survey of all HARP services in Victoria, excluding one paediatric programme (n = 34). The questionnaire focused upon medication review and exercise prescription, as these are the evidence-based falls interventions with a good fit with HARP services. RESULTS Completed questionnaires were received from 24 programmes (70.6%) that service 15,250 older clients (60+ years). All except one programme screened for medicine use; however, a lower proportion (65% of those that screen) target falls risk medications. Among the 17 programmes responding to the exercise prescription question, all routinely include strengthening exercises, and almost all (n = 15) include flexibility, endurance training and movement of the centre of gravity. A lesser proportion (71%) includes reducing the need for upper limb support. The majority of services (88%) undertake falls risk assessments, and all of these either make referral appointments for clients or refer to other services that make referral appointments for clients. Follow-up of appointments and the resulting recommendations was high. CONCLUSION Screening for falls risk medications could be improved and staff training in exercise prescription for balance challenge in this high-risk group may be needed. Although evidence-based falls prevention practice within Victorian HARP services appears strong, the effect on falls risk may not be as high as that achieved in randomized trials.Rationale, aims and objectives The extent to which best practice for falls prevention is being routinely delivered by health care providers for community-dwelling older adults is unclear. We investigated falls prevention practice among Hospital Admission Risk Programs (HARP) that provide and coordinate specialized health care for people at high risk of hospitalization. Method Cross-sectional survey of all HARP services in Victoria, excluding one paediatric programme (n = 34). The questionnaire focused upon medication review and exercise prescription, as these are the evidence-based falls interventions with a good fit with HARP services. Results Completed questionnaires were received from 24 programmes (70.6%) that service 15 250 older clients (60+ years). All except one programme screened for medicine use; however, a lower proportion (65% of those that screen) target falls risk medications. Among the 17 programmes responding to the exercise prescription question, all routinely include strengthening exercises, and almost all (n = 15) include flexibility, endurance training and movement of the centre of gravity. A lesser proportion (71%) includes reducing the need for upper limb support. The majority of services (88%) undertake falls risk assessments, and all of these either make referral appointments for clients or refer to other services that make referral appointments for clients. Follow-up of appointments and the resulting recommendations was high. Conclusion Screening for falls risk medications could be improved and staff training in exercise prescription for balance challenge in this high-risk group may be needed. Although evidence-based falls prevention practice within Victorian HARP services appears strong, the effect on falls risk may not be as high as that achieved in randomized trials.

Safety-Related Improvisation in Led Outdoor Activities: An Exploratory Investigation into Its Occurrence and Influencing Factors

The dynamic nature of led outdoor activities means that, despite activity providers’ best efforts, activity leaders can be exposed to unanticipated situations for which no procedures exist. Improvisation, the spontaneous, real-time conception and execution of a novel response, has been identified as a potential means of maintaining safety in such situations in other safety critical domains. This study examines improvisation in the led outdoor activity context with the intention of adding to the body of knowledge around activity leader decision making. In this exploratory investigation a survey study was undertaken in order to determine whether safety-related improvisation occurs during led outdoor activities, and also to identify the circumstances in which it occurs, the form it takes, and to establish by what factors it is influenced. Over 50% of respondents reported improvising in at least half of their activities, commonly as the result of unanticipated environmental conditions and/or the need for easier procedures. Respondents identified a range of factors that influenced their ability to improvise, many of which overlap with those found in other safety critical domains, but some that appear to be unique to led outdoor activities.