2351-9789 © 2015 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
Peer-review under responsibility of AHFE Conference
Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
Available online at www.sciencedirect.com
6th International Conference on Applied Human Factors and Ergonomics (AHFE 2015) and the
Affiliated Conferences, AHFE 2015
All about the teacher, the rain and the backpack:The lack of a
systems approach to risk assessment in school outdoor education
Clare Dallat*, Paul M. Salmon, Natassia Goode
Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Faculty of Arts and Business,Locked Bag 4,
Maroochydore DC,QLD, 4558, Australia
Inadequate risk assessment has been highlighted as a contributing factor in the deaths of several children participating on school
outdoor education programs. Further, whilst the systems thinking approach to accident prevention is now prevalent in this
domain, the extent to which schools consider the overall led outdoor system during risk assessment processes is not clear. The
aim of this study was to determine whether the systems thinking perspective has been translated into risk assessments for outdoor
programs. Four school outdoor education risk assessments were analysed and Rasmussen’s (1997) Risk Management framework
was used to map the hazards and actors identified in the risk assessments. The results showed that the hazards and actors
identified reside across the lower levels of the Accimap framework, suggesting a primary focus on the immediate context of the
delivery of the activity. In short, from a systems perspective, not all of the potential hazards were identified and assessed. This
suggests that current risk assessment practice is not consistent with contemporary models of accident causation, and further, key
risks could currently be overlooked.The need for the development of a systems theory based risk assessment process is
© 2015 The Authors. Published by Elsevier B.V.
Peer-review under responsibility of AHFE Conference.
Keywords:Led outdoor sector; Systems-thinking; Risk assessment; Hazards
E-mail address: email@example.com
© 2015 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
Peer-review under responsibility of AHFE Conference
1158 Clare Dallat et al. / Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
Risk assessments are not a new requirement for outdoor education programs, although there remains confusion
over how to conduct them [1-5]. Australian Workplace Health and Safety legislation
(e.g. www.worksafe.vic.gov.au; www.worksafe.qld.gov.au) and Education Departments (e.g. DEECD, Victoria;
DET, NSW) mandate that a risk assessment should be completed prior to the conduct of an activity or program.
However, recent findings from the Coroners Courts identified inadequate risk assessment as a key contributing
factor in the deaths of several children participating on schooloutdoor education programs [6, 7].The second of these
inquests  highlighted the lack of a comprehensive risk assessment methodology as one of the key challenges
facing the domain.
The domain’s literature is populated with a significant number of articles detailing specific methodologies for
risk assessment [8, 3, 4, 9, 5]. Parkin and Blades , for example, recommend that, “three factors need to be
considered when identifying risks: the participants, the equipment and the environment” (pp. 11). They also suggest
that hazards in combination may lead to an adverse outcome and as such, “risk identification should include the
identification of all (these authors’ emphasis) likely risk combinations (e.g. participants/equipment/ environment
hazards -potential and likely)” (pp.10). This statement is indicative of the majority of articles that advocate a
similar approach to risk assessment in the led outdoor sector. This dominant ‘Participant, Equipment and
Environment’ approach appears to limit the potential factors which require consideration during risk assessment to
the immediate context of, and within, the confines of the activity itself.
This approach appears to be counter to current thinking in the led outdoor activity domain regarding accident
causation, as well as within the broader field of safety science. Within the led outdoor activity domain, it has been
established that systems models are the most appropriate for understanding accidents and preventing future
occurrences [10, 11].Recent analyses of both minor and fatal incidents within this domain has demonstrated that
multiple contributory factors from across the led outdoor activity system were in fact present . This perspective
has long been the driving force behind accident analysis and prevention in other safety critical domains [12, 13,14].
Having established that systems models are the most appropriate for accident analysis and prevention within the
led outdoor activity sector, a domain-specific systems accident analysis method was developed [10, 11, 15, 16]. This
involved adapting Rasmussen’s  framework to describe the led outdoor activity system. The framework (known
as UPLOADS) consists of six system levels: government bodies, regulatory associations, activity centre planning,
local area government, schools and parents; supervisory and management decisions and actions; decisions and
actions of leaders, participants and other actors at the scene of the incident; and equipment, environment and
meteorological conditions. The purpose of the method is to guide investigation and the analysis of incidents.
Potentially, it could also be used to evaluate the comprehensiveness of risk assessments for outdoor education
programs, as it describes all of the hazards within the outdoor activity “system” and where they reside, as well as the
actors involved in the provision of activities.
The systemic nature of accidents requires that any risk assessment process focuses on risks across the system in
which activities are provided. Despite this, the extent to which led outdoor activity providers consider the overall led
outdoor system during risk assessment processes is not clear. Certainly the literature suggests that the focus is
mainly on the leader and participants, the equipment being used, and the environment, which in turn suggests that
various parts of the system are being ignored. The aim of this study was to investigate whether the systems thinking
perspective on accident causation was adopted in four recent risk assessments for school outdoor programs.
Rasmussen’s Accimap framework was used to map the identified hazards and their interactions considered in
the risk assessments across the led outdoor activity system. In addition, this paper will aim to describe: 1) the types
of hazards that are currently considered in risk assessments for outdoor education programs in schools; and 2) the
actors that are identified as performing a role in controlling the risks associated with these hazards.
Clare Dallat et al. / Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
The study involved a qualitative analysis of four publicly available risk assessments undertaken by schools
conducting outdoor education programs. The study was approved by the University of the Sunshine Coast Human
2.2. Identification of risk assessments
The search engine Google (www.google.com.au) was accessed on the 3rd February 2015 and the following search
term: ‘risk assessment for outdoor education programs in Australia’ was entered, achieving 825,000 results. The
search results were reviewed in concurrent order (starting from page 1) for current, accessible and completed
school-based outdoor education risk assessments, which also provided a reasonable geographical representative
sample from across Australia. Two risk assessments that met the above inclusion criteria but which, after closer
inspection did not contain any identified hazards, were excluded. The first four risk assessments meeting the
inclusion criteria were accepted for analysis.
2.3. Risk assessment content analysis
Each risk assessment was coded individually, which involved identifying all of the hazards and actors. To assess
the extent to which the risk assessments adopted a systems approach, the UPLOADS Accident Analysis Framework
was then used to represent the findings [10, 17, 11, 15, 16]. This involved placing the hazards and actors identified
onto the appropriate level of the framework. For example, if the hazard ‘severe weather’ was identified in the risk
assessment, it was placed at the ‘Environment and meteorological conditions’ level. If the hazard of becoming
‘Lost’ while participating in the activity of bushwalking was identified, it was placed at the ‘Decisions and actions
of leaders, participants and other actors at the scene of the incident’ level. For the actors, if, for example, instructors
and participants were identified, this was placed at the ‘Decisionsand actions of leaders, participants and other
actors at the scene of the incident’ level. If parents were identified, this was placed at the, ‘Activity Centre
Management, planning and budgeting, local area government, parent and schools’,level.
3.1. Overview of risk assessments
Of the four risk assessments, one was completed for a single activity that a school group was to participate in
(cycling), while the second was created to cover two activities (‘mass surf swims’ and ‘creek swims’). A third
focused on multiple activities occurring on an outdoor education program occurring within a centre (a ‘hard-top’
location where there is a variety of activities available and accommodation is both camping and bunk bed style). The
fourth risk assessment centred on the activity of camping in a school outdoor program. Three risk assessments were
state based and represented three different states in Australia, with the final assessment designed to be used for
schools operating nationally (different schools under the same faith-based governance). Across all four risk
assessments, 21 led outdoor activities (e.g. abseiling, cooking, canoeing, surf swims and cycling) were identified.
3.2. Hazards and associated UPLOADS levels
Overall, 77 types of hazards were identified across the four risk assessments. 76 of the hazards were found to be
situated across the two lower levels of the UPLOADS framework; these levels being, ‘Decisions and actions of
leaders, participants and other actors at the scene of the incident’ and, ‘Equipment, environment and meteorological
1160 Clare Dallat et al. / Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
Table 1.Overview of the information contained with the four risk assessments.
State Number of
Role of staff who
Approval of Risk
Risk Assessment 1 NSW 18 23 4Unknown No
Risk Assessment 2 QLD 223 6Teachers (14
Risk Assessment 3 Victoria 115 3Unknown No
Risk Assessment 4 National 116 2Unknown Yes
conditions’. One hazard (Student Numbers) was identified at the ‘Supervisory and management decisions level’
The Accimap containing the identified hazards for the four risk assessments is presented in Figure 1. The
numbers in brackets represents the number of times they were mentioned. The most commonly populated level was
the ‘Environment and meteorological conditions’ level (42 hazards) whereas the next level, ‘Decisions and actions
of leaders, participants and other actors at the scene of the incident’, contained 34 hazards. Only one identified
hazard, “Student Numbers” was represented in the ‘Activity Centre Management, planning and budgeting, local area
government, parent and schools’ level. No other levels of the Accimap were represented from the hazards identified
within the four risk assessments.
At the ‘Equipment, environment and meteorological conditions’ level, 64% of the UPLOADS taxonomy was
represented, whereas only 17% appeared at the ‘Decisions and actions of leaders, participants and other actors at the
scene of the incident’ level. This percentage reduced even further upon reaching the ‘Supervisory and management
decisions and actions’ level of the UPLOADS framework, with only 10% of the UPLOADS causal factor taxonomy
factoring in the risk assessments.
Hazards and risks associated with physical injuries and illnesses featured prominently with,“Pre-existing
conditions”, “falls”, “strains and sprains”, “fractures”, “burns”, and “allergic reactions” together accounting for 50%
of all hazards represented across the ‘Decisions and actions of leaders, participants and other actors at the scene of
the incident’ level of the framework.
Within the ‘Environment and meteorological conditions’ level, weather and subsequent weather conditions
presented strongly. “Lightning”, “temperature”, “rips”, “drowning” and, “weather conditions”, collectively
accounted for 33% of the identified hazards at this level of the framework.
Within the remaining hazards populated on this level of the framework, there was significant variance in the
types of hazards identified. For example, one risk assessment identified “Environment being harmed by a human” as
a hazard requiring action, whereas another referred to the potential for “Allergic reaction to Arts and Crafts
3.3. Actors identified
It became evident that the higher the number of hazards that were identified in the risk assessments, there were
subsequently more actors which were also documented within the risk assessments. This finding however, was not
repeated in relation to a correlation between the number of activities and the number of actors. In this case for
example, Risk Assessment 1 had 16 identified activities, yet only four actors whereas, Risk Assessment 2 had two
activities yet identified six actors with responsibility for risk control implementation.
An ActorMap for the actors represented in the four risk assessments is presented in Figure 2. Three levels of the
ActorMap were populated with actors identified in the risk assessments. The ‘Decisions and actions of leaders,
participants and other actors at the scene of the incident’ level contained the highest number of actors referred to
within the four risk assessments (12 in total). One risk assessment (surf swim and creek swim program) highlighted
the role of “Parents” and “Local Council”, consequently populating the ‘Activity Centre Management, planning and
budgeting, local area government, parents and schools’ level. Another risk assessment (the multi-activity program
with both camping and bunk bed options) included the “Catering Manager” role in the risk assessment process; this
populated the ‘Supervisory and management decisions and actions level’ of the ActorMap.
Clare Dallat et al. / Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
Regulatory bodies and
Local area government,
schools and parents
Activity cen tre
Decisions and actions of
lead ers, par ticipa nts
and other actors at the
scene of the incident
Medical conditions (3)
Slips and trips (1)
Trailer reversi ng (1)
Limited skill (1)
Strains and sprains (2)
Special needs group (1)
High risk behaviour (1)
Injury from arrow (1)
Allergic reacti on (3)
Negative impact with
another group (1)
Lost student (1)
Infectio n (1)
Sloping ground (1)
Environment being harmed
by human (1)
Wild animals (1)
Exposed ridges/hollows (1)
Treed campsite (1)
Cattle grids (1)
Steep terrain (1)
Unknown site (1)
Animal bites/stings (3)
Tree fall (1)
Road hazards (1)
Water visibility (1)
Temperature hot/cold (3)
Weather conditions (2)
Water quality (2)
Falling objects (1)
Clothing entangled in bike
Bike failure (1)
Trailer decoupling (1)
Arts and crafts material
(allergic reaction to) (1)
Vehic les (1)
Equipment failure (1)
Fig. 1.Accimap representing hazards identified within the four risk assessments.
The aim of this study was toinvestigate whether the systems thinking perspective on accident causation was
adopted in four recent risk assessments for school outdoor programs. In order to achieve this, the types of hazards
considered in four risk assessments for outdoor education programs in schools were identified, along with the actors
who were recognized in the risk assessments as performing a role in controlling the risks associated with these
hazards. Both hazards and actors were then mapped using a led outdoor activity accident analysis frameworkbased
on Rasmussen’s  Risk Management Framework [10, 11, 15, 16].
The findings suggest that the risk assessment approaches within the four risk assessments may not be consistent
with contemporary models of accident causation. The identified hazards and consequent risk assessment strategies
were found to populate only the lower levels of the framework, with 76 of the 77 hazards identified focussing on the
immediate context of the activity only. Further, the actors identified populated primarily across the immediate
delivery context of the activity –those at the so-called ‘sharp-end’ were most commonly referred to within the risk
assessment. The findings of this study undoubtedly reflect the risk assessment approach most commonly referred to
within the domain’s literature on risk assessment -one that focuses almost exclusively on the immediate confines of
the activity and specifically, on the “People, the Equipment, and the Environment” [2, 8, 3, 4, 9, 5].
A second important finding is that the hazards identified at the lower levels are not consistent with the hazards
known to be prevalent in accidents in this domain. With only 17% of UPLOADS causal factor taxonomy being
represented at the second level of the framework (Decisions and actions of leaders, participants and other actors at
the scene of the incident), it seems evident that even in a level garnering significant attention in the risk assessments,
many hazards were in fact not being considered at all. Further, at the level which represented most congruence
between the four risk assessments and the UPLOADS causal factor taxonomy (‘Equipment, environment and
1162 Clare Dallat et al. / Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
Government Policy and
Regulatory Bodies and
Local area government,
parents, schools and
Physical processes and
Manag ers (e.g.
progra ms,tra ining ,
Risk Assessment 1
manag ement /
board l evel
Local Govt and
Risk Assessment 2
princ ipals an d
Regul atory bodies
bodie s Auditing bodies
Peak bodies for
Activ ity Stand ards
of Austr alia e.g.
Mete orologica l
Fig. 2.Led outdoor activity ActorMap.Adapted from . (Shaded areas represent actors considered within the four risk assessments).
meteorological conditions’), with only 64% of the UPLOADS causal factor taxonomy represented, many hazards at
this level were also not being considered.
So what do these findings tell us about risk assessment for led outdoor activities and programs? First and
foremost, they suggest that current approaches to risk assessment are in contradiction to current thinking and
approaches to accident causation, both within the led outdoor domain itself (e.g. Salmon et al, 2014), and within the
wider field of safety science [14, 13, 12]. Multiple studies have demonstrated that numerous contributory factors,
evident from across the led outdoor activity system, were present in both minor and fatal incidents within this sector
. This systemic nature of accident causation requires any risk assessment process to focus on risks across the
system. In other words, by accepting the presence of contributory factors which lead to accidents, of all magnitudes,
throughout the system, we could reasonably expect the hazards found in risk assessments to populate across all
levels of the UPLOADS framework, and not solely within the lower levels. In short, the factors (or hazards) that
were found to be contributory following an incident, must have also been present, prior to the incident. By the
absence of such factors populating the majority of the UPLOADS framework in this study, it seems that potential
hazards, and consequently, potential risks to participants, were not being identified on these outdoor education
programs. A second important implication is that the hazards identified at the lower levels may not be paint the full
picture of hazards present at these levels. The hazards identified only covered 22% of those included in the
UPLOADS taxonomy (which was developed based on a comprehensive assessment of the contributory factors
involved in led outdoor activity accidents). This suggests that current approaches also do not support the
identification of the range of hazards at the leader, participant, equipment and environment levels. Therefore, in
short, the focus of current risk assessment approaches is too narrow, both in terms of the levels of the system
considered, and in terms of the leader, participant, equipment and environment hazards considered.
It is worth noting that hazard identification is only one aspect of a risk assessment process, as described in most
WHS guidelines and international standards (ISO 31000, AS/NZ 4360). Additional steps involve assessments of the
potential severity and frequency of associated risks arising from interaction with the hazard, before documented
controls can be considered, prioritised and implemented (IEC 31010:2009 Risk Management –Risk Assessment
Clare Dallat et al. / Procedia Manufacturing 3 ( 2015 ) 1157 – 1164
Techniques). If hazards exist throughout the system, associated with the conduct of an outdoor education program,
but which remain unidentified, it seems evident that the processes with which to reduce the potential of harm
associated with those hazards, will not be implemented. A systems perspective posits that effective and appropriate
risk controls must also target the interactions between the higher-level factors and the lower level factors . An
interesting further line of research would be to assess the other components of risk assessment and their concurrence
with contemporary models of accident causation. Does, for example, the assessment of severity take into account
interactions between components and the fact that small events can lead to emergent behaviours of a far greater
magnitude (i.e. large scale catastrophes)?
The recent coronial inquest into the death of a student on an outdoor education camp in Victoria, Australia ,
highlights the tragic yet unintended, consequences of failing to consider hazards and risks within the entire system.
One of the Coroner’s findings surrounded the inappropriateness of the dam as a place to swim in in the first place.
Upon analysis of the incident, it became evident that various “Actors” involved with planning the activity (well
before the actual activity occurred) believed that it was both someone else’s role to ensure adequate, qualified
supervision at the dam and further, the assumption was made on historical evidence from previous camps, that a
qualified lifeguard would be provided (it later became apparent that this person had in fact left their position, several
years prior). It is possible that, employing a systems based approach to risk assessment, where hazards at all levels
within the system, were identified and potential risks managed, that this gap would have been identified, and
consequently may have led to the essential controls being implemented to reduce the likelihood of such a tragedy
Finally, the limitations of the study and directions for future research should be considered. As a proof of concept
study only a small sample of risk assessments were analysed. This limits the ability to generalise these results and
findings to the wider domain. However, given that all the existing guidance regarding risk assessment for outdoor
education programs focusses primarily on hazards associated at the activity delivery end -namely, on people,
equipment and the environment, it seems highly likely that the risk assessments included in this study are reflective
of the sector.
To conclude, this study has demonstrated that, in four recent risk assessments, a systems approach was not
employed. This is inconsistent with what we know about accident causation and potentially represents a key failure
of current approaches. At worst, this suggests that we may not currently comprehend the hazards and risks present
during led outdoor activities. More work is therefore required to enable potential hazards and risks across the entire
led outdoor system to be identified and importantly, the potential interactions of these hazards and risks to be
understood. The various actors across the same system need to be identified, as well as their interactions, with both
each other, and the potential hazards and risks. It may,for example, be the case that by adopting a systems based
methodology to risk assessment that additional actors will be identified. Nonetheless, in order for this work to occur,
we need to understand better the current barriers to developing and implementing systems-based approaches to risk
assessments within the led outdoor activity domain. The wellbeing of the entire system could depend on it.
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