Annual surveillance is coming up for a lot of operators soon.

One of the things you'll be asked is how you review incidents and analyse trends. Section 8.2 of the Safety Audit Standard for Adventure Activities 2017 (SAS) says this: "The operator must establish a process for investigating and reviewing incidents, understanding the underlying causes, identifying improvements to the SMS, and analysing trends.

Recommendations from incident reviews must be implemented and communicated to staff and relevant other parties."

It's pretty common for operators to report their incident pretty well and conduct comprehensive interviews with their staff. What isn't always done well is the second bit - understanding underlying causes and identifying areas for improvement.

We often see detailed records of events leading up to the critical moment of injury or incident but significantly less focus on why it happened. Often "human error" is concluded to be the root cause an no improvements are suggested - "these things happen in adventure activities, otherwise they wouldn't be adventures".

These things do happen, and will continue to happen, and lives will be enriched and tragically affected for as long as we continue to pursue adventure, and that shouldn't change. 

But while we are providing adventure activities to paying customers in our incredibly beautiful "offices", we need to ensure that we are doing all that we can to ensure everyone goes home safely afterwards. "Human error" can cause incidents, as humans we're fallible. With that knowledge, in an investigation we need to ask why human error wasn't considered as a hazard when assessing the risks. We need to move away from "who" and focus on "what"; If we look at what circumstances or procedures were in place, we can start to identify what made it possible for that person to do the wrong thing. We can't prevent human error, but we should strive to improve processes where an error is less likely to lead to a significant event. Change (continual improvement) happens through learning. This is most likely to happen when we stop looking to blame a person, and start looking to improve the process that allowed the error to occur.

I learnt a new term recently - "fundamental attribution bias". This is the tendency to blame the situation or conditions if I make a mistake but to attribute human error to the same incident if it happens to someone else! The flip side of that coin is we accept success to be a result of our own hard work, but when others succeed, we attribute this to the opportunities they had, and not their hard work! - Feel free to forget the term, but there's an interesting lesson here.

"What if I haven't had any incidents?" Don't despair, if you're engaging with good technical advisors (Sections 4.2, 5.1 & 10 of the SAS), they should have a good idea of what incidents your sector has experienced and how the reviews/investigations went. It would be a waste if we didn't use previous incidents to minimise the chance of making a mistake that's already been made by someone else. 

Remember, mistakes are much less likely to happen when we have systems in place that have considered human error and planned ahead for it.