Risk Management and the Accident Process

Dr. Robert B. Kauffman

Robert B. Kauffman, Ph.D.

Most of Dr. Kauffman’s professional career has been involved in the accident process. This involvement parallels and complements his involvement in boating safety. He has written a textbook, created nationally distributed videos, created wallcharts, and written numerous articles on the subject. Several of his films and videos incorporate the accident process. He taught a course on the topic of risk management.

Accident Process

Barrier Analysis

After going through the development of several model over numerous years, the current rendition of the accident process model embodies barrier analysis. Barrier analysis offers several advantages (see model on the right).

  • Barrier analysis is widely used. It is used industry wide by the DOE, Army Corps of Engineers, DOD, and NASA. It can easily be adapted to other settings including recreation and parks.
  • It is causal. Causality strengthens the use of the model. This means that if any of its components are missing, an accident won’t occur (i.e. necessary). And, if all the components are present, an accident must occur (i.e. sufficient).
  • It is intuitive. The Swiss Cheese model which incorporates the barrier analysis components is easy to understand. Even the more sterile model derived from MORT is easy to understand also (see the video).
  • Definition: Accidents are the result of an unwanted energy transfer from a source to the target (e.g. people or things) where the barriers that could potentially prevent the energy transfer are less-than-adequate (LTA). An article and video on accidents as an energy transfer are presented in the resource materials below.
  • Worksheet. To be be useful, a worksheet is available that incorporates the barrier analysis components.

Rescue Curve

Developed by this author, the rescue curve states that when an incident occurs as time increases the probability of survival or not having injury, damage, or loss decreases. The lines of defense are safety and prevention, self-rescue, rescue by others in your group, rescue by others outside your group including the rescue squad, and injury, damage, or loss. It is a slippery slope and this is why experienced or prepared people front load their experience with safety and prevention.

Check out the 911 Syndrome. These are people who begin their experience expecting that they will begin their rescue experience with rescue by others outside your group. When something goes wrong, call 911. It is what they can do, not what I can do to be safe or self-rescue. The fire department will put the fire out rather than what I can do with a fire extinguisher. I will call AAA and they will change my flat tire. I should note that there is nothing wrong with calling the fire department or AAA to change the tire.

The rescue curve was originally developed in the outdoor recreation field although it can be applied to front country situations. The movie Heads Up – River Rescue for River Runners embodies the rescue curve and is included in the resource materials below. I should note that the rescue curve was formalized after we made the movie although we generally understood the concept when we made the movie and that is why it is embedded in the movie. If you watch the video Decide to Return, you will note the rescue curve embedded into the video as a secondary theme. The short alternative reality scenes of what they should have done embodies the rescue curve components. The YouTube connections for both videos are provided below also.

Two texts describing the rescue curve are included in the resource materials. The first is a summary from our textbook. It is titled “Rescue Curve.”A historical note. There was a time when there was seemingly a lot of overlap between the American Canoe Association Swiftwater Rescue Course and the Rescue 3 Course. The rescue curve was used to indicate that they really appealed to different markets. The second publication is an unpublished chapter from my prepper course. It shows how the rescue curve can be applied to settings other than outdoor recreation, in this case prepping. Recently, a YouTube video has been added. It is simply titled “The Rescue Curve.” It provides a good overview of the rescue curve.

Videos

The following materials, Cold, Wet, and Alive, Decide to Return, and to a lesser extent Almost a Perfect Day, depict a day’s activity that lead to an accident. I like using Cold, Wet, and Alive because you can easily project the participant within what is essentially a leaderless group. It is easy to ask the question: “What would you do if you were the leader of this group?” I use a stop action where I stop the video and discuss with the group to assess the situation in terms of the underlying factors. The underlying factors work well with lay groups because they are intuitive and easy to apply to the days activities. In addition, I ask the participants to assess mood of the group. Are they frolicking? Or are they fatigued? If you were the leader, what would you do? Why? Also, we have a discussion regarding why they made the wrong decision at the lunch stop (i.e. Abilene Paradox). Everyone knew that they should end the trip, but they made the wrong decision because their goal was to run the whole river (e.g. group think). Think about the implications in terms of making the right decision had they left a shuttle vehicle at the lunch stop bridge (e.g. trip planning). Also, this changes the goal of the trip.

Cold, Wet, and Alive

When we made the film, it was a hypothermia film with a secondary theme of the accident process. I like to say that it was a film about a hypothermia accident. The film was published in 1989 and in 2007 it was still the most widely used video by boating law administrators. I would suggest reading the YouTube description for the movie. It gives details on the shoot, the “Rocky Horror Movie” story line as a safety video, The “Abilene Paradox” discussion, the graphics, and where the movie was filmed. Click here to go directly to the YouTube video. Read the description for the backstory.

Rocky Horror Show. Let me provide some insight from this film that we incorporated into other safety videos. The problem with the crash and burn automobile videos is that the audience concludes that “I don’t drive like that.” Quickly, they turn off and tune out the message. The secret to why Cold, Wet, and Alive and later Almost a Perfect Day works is the same reason why the “Rocky Horror Show” was so popular. The audience was in on the gig. The audience knew what was going on before the actors in the movie knew. The narrative and computer graphic call-outs in Cold, Wet, and Alive provide the audience with this information. The audience is able to predict what is going to happen before it does. In addition, the main characters are likeable. For anyone making safety videos, it is a strategy worth considering. If you view our most recent video, “Almost a Perfect Day,” it is actually a conceptual remake of Cold, Wet, and Alive.

Decide to Return

Made in 2007, Decide to Return is a conceptual remake of Cold, Wet, and Alive except that it emphasizes the decision making process rather than how you get hypothermia. Also, its setting is with sea kayaks rather than a river trip. Click here to go to the YouTube site and learn a little about the backstory.

Almost a Perfect Day

Our most recent video was completed in 2014. It is the story of how the environmental stressors lead to a boating accident. It too is a remake of “Cold, Wet, and Alive” except it occurs in a power boating setting and its focus is on the environmental stressors rather than hypothermia. It depicts an accident process occurring throughout the day. Click here to go to the “Almost a Perfect Day” video.

Outdoor Recreation Leadership

Applying the Situational Leadership to Outdoor Recreation

The situational leadership model is foundational in leadership. The purpose of this video is to apply Hersey’s model to the outdoor field. Numerous examples, including mismatches, are presented illustrating the situational leadership model and its applicability to outdoor settings.

Unlike most leadership models that are static and focus exclusively on the leader, the situational leadership model starts where the follower is at, is a variable leadership style that adjust to the changing needs of the follower, and the leader exercises their leadership style based on the assessment of the follower’s needs. Hersey’s book is a great read and well worth purchasing. The benefit of this video is that it explains in depth the workings of his model as applied to the outdoor setting. Good leadership involves a lot of factors. The situational leadership model provides an excellent foundation. It is a key component in developing good leadership and in reducing accidents.

Avoiding Accidents with Operational Risk Management (ORM)

Operational Risk Management or ORM was developed by the Navy in an effort to reduce accidents in high risk areas on aircraft carriers and other Navy ships. A key element of ORM is that it involves the individual in the decision making process. If a sailor on the flight deck sees a eminent accident, he can halt operations. Involving the individual in the decision making process complements managing the organizational culture with policies, practices, and procedures.

In the Navy’s ORM paradigm, the sailor assesses the severity and probability of an incident occurring. Severity is the effect of the hazard and is sub-divided into four categories. Probability is the frequency or likelihood of occurrence over time and is also subdivided into four categories.

This video presents a simplified version of the Navy’s ORM that is adaptable to outdoor recreation situations (3×3 ORM Matrix). Its triage approach to decision making makes it more intuitive. Condensing categories with the same outcome results in a nine cell table with three recommended actions: Stop and take immediate action, modify, or monitor.

Risk Management Plans

The power point below relates to Chapter 8 in our textbook titled: Integrated Risk Management. It is a good primer on the process.

RM-Ch08_RiskMgmtPlans1804_v2Download