The following article appeared in the Autumn 2024 edition of Te Whakatika, the journal of Education Outdoors NZ. I am currently running workshops based on this material.

Developing a Fatality Prevention Mindset

Introduction

Since 2000 there have been 22 fatalities in outdoor settings involving school students/staff in Aotearoa New Zealand. The vast majority of teachers or outdoor educators will never encounter a fatality so cannot rely on personal experience to understand how fatalities might be prevented. When a death occurs it is often assumed that it was due to a freak accident. This is a natural assumption given the sector has operated under various risk management regimes for decades. However detailed analysis by Andrew Brookes reveals that “few OE deaths prove to be caused by misfortune alone. Most involve failures to learn from the past” (Brookes, 2018, p. 1). In order to learn from the past we can review reports of previous fatalities; by doing so we may avoid the situation where newer educators repeat old behaviours (Brookes, 2011). The purpose of this paper is to highlight the importance of developing a Fatality Prevention Mindset.

What is a Fatality Prevention Mindset?

A Fatality Prevention Mindset requires us to understand that while a fatality might be considered rare, it is of such a magnitude that the need to develop expertise in prevention becomes a non-negotiable. Fatality Prevention requires educators to distinguish between situations where a poor decision could be relatively inconsequential and those in which it could be deadly. Developing a Fatality Prevention Mindset requires familiarisation with the events that led to previous fatal incidents with the view to building expertise as to the cause(s).

Prevention does not require fore-knowledge of exactly when and where a tragedy will occur – it is sufficient to know under what conditions fatal incidents could occur, in order to deploy precautions just in case. (Brookes, 2018, p. 11)

When developing a Fatality Prevention Mindset it is helpful to avoid judging an individual based on what they could or should have done in the past. Instead, prevention is better served by considering what any individual could do in a similar situation and how they can be equipped, in the broadest sense, to take appropriate action (Brookes, 2018).

The Prevention Perspective

Fatality Prevention is firmly focused on the most immediate causes of an incident – those which an informed person can act upon to prevent future occurrences. It does not seek to go down the ‘rabbit hole’ of identifying every possible cause and then looking for the sequence of events that influenced or surrounded that cause (ad infinitum). Put simply, it looks for the ‘but for’ or ‘what if’ line of questioning.

The Three Foundations of Fatality Prevention

The following points are drawn from Andrew Brookes’ extensive research in this area.

1. There must be strict aversion to fatal incidents. This means consistently making Fatality Prevention the overriding priority. As Brookes(2018) has noted,

As in almost any industry or community sector, production pressure and financial constraints are in constant tension with fatality prevention.  Fatality prevention can require programs to be modified, delayed, or cancelled.  It occupies staff time and effort in ways that do not contribute to the primary goals of the organisation. It requires constant, active attention, because if precautions are neglected usually nothing happens.  A bell doesn’t ring, at least not until and unless tragedy ensues. (p.226)

• There has to be a competent decision maker who understands local hazards, observes conditions, and can take action. Deaths have occurred because leaders were unaware of a potentially deadly circumstance or hazard. Incidents occur in specific places with unique features. Knowledge of specific places must be gained from direct experience and sources such as maps, forecasts, weather/flood records, and local knowledge holders.  The importance of place-specific knowledge, gained from experiences in a variety of seasonal conditions, is often underappreciated in outdoor education. The importance of place knowledge, from both a safety and pedagogical perspective, has been well articulated (Brookes, 2018; Wattchow & Brown, 2011). Place-responsive outdoor education, rooted in familiarisation visits, encourages active consideration of potential sites of fatal incidents. Unfortunately, staff lacking local knowledge and experience figure repeatedly in fatal accident cases (Brookes, 2018). As Brookes (2018) has pointed out,

The most common systematic problem in the OE field by far; based on fatality cases, is a tendency for organisations to deploy staff with insufficient expertise, and to over-rely on procedures, rules, and written guidance. (p.26)

• Key individuals must have knowledge of past fatal incidents. Deaths have occurred because those responsible for programme design and delivery failed to envisage what could go wrong or how the situation was developing here and now. Those responsible for others in the outdoors must be familiar with past cases, discuss incidents, and put the learning from past tragedies into action. All participants in the delivery, management, and governance of outdoor education need to take responsibility for ensuring that a Fatality Prevention Mindset permeates their organisation. This is referred to as ‘defence in depth’ (Brookes, 2021). While the school Principal or Board Chair may not have familiarity with individual incidents they should understand the absolute importance of Fatality Prevention and have policies in place that enable operational staff to gain Fatality Prevention skills.

How does Fatality Prevention differ from Risk Management?

Risk Management and Fatality Prevention are not the same thing. Risk Management attempts to identify and imagine all risks that might be encountered  (e.g., equipment loss, damage to an organisation’s reputation). Fatality Prevention uses case studies, to learn from previous incidents, with a specific focus on preventing death. A Fatality Prevention approach does not negate the need for risk management policies and processes – however, it acknowledges that these are insufficient to prevent a death. A strict aversion to fatality approach requires that risk management processes are complemented with a thorough understanding of the causes of previous fatalities in outdoor education to ensure that mistakes are not repeated.

Case Based Learning and the Development of Expertise

Fatality prevention has a specific focus on using case studies to identify specific circumstances that have led to deaths. It is about developing the knowledge to recognise patterns of events/circumstances that contribute to expertise in decision making. Workshops draw on Coroner, Worksafe, and Maritime NZ reports.

Case-based Fatality Prevention does not require that every uncertainty or possible oversight is identified – only those which are ‘but for’ and can lead to deadly outcomes. The more cases that are studied the more you will develop a recognition of patterns. Being familiar with previous cases will help you to develop, “expert intuition that recognises when, where, and how to intervene. Cases point to how to prevent deaths in the outdoors, and also provide insights into how individuals or organisations can fail” (Brookes, 2018, p. 2). Case-based learning can take time and effort but is required if we are seeking to develop expert intuition.

Concluding thoughts

Following a death on an outdoor trip schools and parents may understandably ask, “How can I know that my child/student will come back alive?” The research helps us to respond: “your child/student will be supervised by a competent leader who is fatality averse, who understands the causes of past fatalities, and who knows the programme and specifics of the location well enough to apply that understanding” (paraphrase of Brookes, 2021).

Analysis of previous fatal incidents reveals that almost all “freak accidents” are preventable. Most outdoor educators, schools, or providers will not encounter a fatal incident but let us not confuse probability with possibility. Adopting a Fatality Prevention Mindset allows us to learn from the loss, pain, and anguish of others in order to avoid playing out an old script.

If we wish to continue running quality outdoor programmes with young people we need to ‘shift the dial’ and take on board lessons from the past. Failure to do so risks another preventable death. Engaging with case studies aligns with outdoor educations’ strong advocacy of ‘reflection on experience’ as a valuable way of learning – we can walk confidently into the future if we look to the past for guidance.

Further information. If you are interested in hosting or attending a Fatality Prevention Workshop please contact Jo Hayes at EONZ (admin@eonz.org.nz) or email me directly mike@eonz.org.nz

References

Brookes, A. (2011). Preventing fatal incidents in outdoor education. Lessons learnt from the Mangatepopo tragedy. New Zealand Journal of Outdoor Education, 2(6), 7-32.

Brookes, A. (2018). Preventing fatal incidents in school and youth group camps and excursions. Understanding the unthinkable. Springer

Brookes, A (2021). Learning from tragedies in G. Thomas et al. (eds.), Outdoor Environmental Education in Higher Education, International Explorations in Outdoor and Environmental Education 9, https://doi.org/10.1007/978-3-030-75980-3_25

Wattchow, B., & Brown, M. (2011). Pedagogy of place: Outdoor education for a changing world. Monash University Publishing.