I thought a response...

...to my recent post deserves its own posting. I hope you don't mind Jeff Baierlein if I exercised my editorial prerogative to do so. Jeff is well-placed to offer a perspective for the edification of practitioners (including my own!). [Check out Jeff's bio here: https://courses.viristar.com/our-team/]

I had written my post adopting a micro or practitioner/operator point of view. When I wrote "the burden of responsibility lies mainly with the ground staff conducting the activity, and the organising entity", I personally adopt the mindset that, at the moment of despatching a participant on the zipline, the buck stops with me. My actions (as a result of training, regulation and experience) had led the participant and I to this critical juncture, after which whatever happens, happens.

But I certainly believe in the chain of safety and the macro perspective as so well described in Jeff's response below:

"A thought about who else can support good safety outcomes: the research into safety indicates that to most effectively reduce the likelihood and severity of incidents, improvement efforts should be made at all levels of the system in which the incident occurred. The complex socio-technical system generally is understood to include government legislation and regulation (and its enforcement); industry associations (in this case examples include ACCT and OLAE) and their organizational accreditation and practitioner certification/qualification schemes, as well as Codes of Practice; the provider (company) organizing the activity, including its policies, procedures, safety culture and standards; the staff directly conducting activities (in this case, the dispatcher/facilitator), and the nature of them design of work tasks. (This primarily from AcciMap and its variants).

There is not good evidence to suggest that the burden of responsibility lies mainly with the ground staff conducting the activity, and the organising entity.

We can see a positive example of this systems-informed approach with the recent follow-up to the incident at Safra Yishun, where organizational accreditation requirements (ACCT) were strengthened, practitioner qualifications (ERCA/ACCT/other) were strengthened, and the government, association leadership and the private sector also became involved in strengthening adventure safety standards across the adventure industry. Having the government support the private sector with workforce development in the post-pandemic context is another part of this systems-informed approach.

One of the ways to understand a safety mishap is to see the commission of an error as a symptom of an imperfect system, rather than simply a failure of the person directly involved. So we must look more deeply, if we wish to help prevent future incidents. Were safety laws and regulations sufficient, and appropriately enforced? Were industry association safety guidelines/codes of practice sufficiently well-developed and disseminated? Do a sufficient percentage of operators follow those guidelines/COPs? Is there a third-party audit system to help ensure that standards are clear, and unambiguously met? Are training bodies sufficiently resourced to make trainings available, and do operators/practitioners have the resources to ensure staff are trained?

In many cases in SG, the answer to these questions is yes, because of the good work of various entities, from training institutions to government to the private sector. And the adventure sector, as you know, is actively engaged in a process of further improvement.

Locking up a dispatcher/facilitator who makes an honest human error is not well-correlated with preventing future incidents. Applying interventions at all levels of the system, however, is."

Regarding the punishment meted out to the instructor, a friend asked me yesterday if I thought it was 'harsh'. I replied (and this is my personal opinion):

1. I think it can’t be helped especially with the recent sentencing of the Camelot instructor. A message had to be sent to the industry and the public and it had to be this.
2. Such sentences may encourage realignment of mindsets… so those who don’t have the right attitude might buck up or leave the industry. Practitioners who do their job properly or organisations with adequate regulatory and training regimes should not have to worry. I am however concerned about the possible imposition of draconian measures or regulations that assume our current industry practices are weak or necessitate more oversight.

[The above part is especially difficult to write because I know the instructor involved in the case. I don't know the particulars of the case, so I'm really just sharing my thoughts without prejudice to the instructor or anyone else involved.]