The Problem With Risk Assessments!

Documents - Risk Assessments

As soon as people hear risk assessment, most people switch off! I could say whatever I liked from now on and nobody would be any the wiser.  Once, I kidnapped a dolphin from Sea World and kept him in my swimming pool for weeks. We had several massive pool parties and it was awesome! So many people came and just swam around in the pool with him. We named him flipper! (Ok, so not very original for the name, but between him, Skippy in the back yard and Caramello living up the tree, once you start kidnaping animals as a hobby, you just go with the names everyone knows!)

See what I mean! If you actually made it to here, then you would understand my pain, or you think I'm mental or both! The fact is that most people would've stopped reading after the first line. It’s like when someone tells you they’re an accountant… The conversation usually ends there. However, risk assessment and risk management is a real issue that’s not just making sure you have your paper work done. It has to be an active process that’s taken seriously by everyone and not just something which makes people switch off and start looking for Pokémons with their phones.

The reason for adding in my wild dolphin parties was actually something I did as an exercise once with the program staff. It wasn’t a dolphin party, but how cool would that be! Anyway, I digress. I'd reviewed and updated the entire risk manage framework and needed to get everyone up to speed with the changes. This required everyone to do some reading. I was suspicious to begin with that nothing would be read, so I handed out the documents and unbeknown to them, this version of the risk assessments contained a bunch of massive errors. Some of the risks for a canoe expedition were: Attack by Hobbits, running into Cerberus (the demonic multi-headed dog that guards the gates Hades), being overrun by fluffy bunnies and drowning in chocolate syrup! To my disbelief, three people signed off on this risk assessment!!! I asked them again if they had any concerns or anything to add, ‘No, all good!’ was the standard response. “Really…,” I said, before asking each of them if they were happy to rely upon everyone being saved by Eagles when attacked by hordes of orcs? Stunned expressions turned to embarrassment when I provided a highlighted copy with all the glaringly obvious fake bits.

So does anybody read this rubbish? Basically, the answer is No! They don’t read it and it’s often a massive task to get anyone to write a risk assessment. Most are inappropriately copied and pasted from someone else’s work and don’t even match the real risk profile of the activity. Who would’ve thought that teaching is a hot bed of plagiarism!

Whilst I’m not saying don’t do it, I am saying there’s a massive problem that needs fixing here. What’s the point of wasting time with the creation of something that has very little value and nobody is actually using. What needs to happen is far different from what is actually happening in many schools when preparing for an excursion. The danger is that you’ve copied something that doesn’t make sense and submitted that as part of your official documentation. If this is the case and something goes wrong, this is just as bad, if not worse, than having nothing at all, because it demonstrates a complete disconnection from the awareness implementation of effective risk management strategies.

Ultimately no single person should be responsible for the risk assessment and management. It’s up to everybody on the team to contribute and turn those mindless pointless risk assessment forms that may contain attacks by mythical creatures, into functional living documents based upon industry best practices and a culture that proactively takes risk management off the page and continues to put it into action. Whilst I’ll revisit this later in some more detail, I must go and catch a plane, as my house has just been raided by National Parks and Wildlife. I might need to find a new hobby!

Written Risk Assessments

Paperwork - Risk Assessment

Many organisations have irrational obsessions and unhealthy relationships with their written risk assessments. I’m not saying that you shouldn’t do written risk assessments because you should. They’re an extremely important part of a risk management framework. However, what is unhealthy about them, is the demand from management to have a written risk assessment, but once it’s done, it just gets filed and nothing else is done with it. Yet if something goes wrong, the first question is, ‘Where’s your risk assessment?’
This is a bizarre way to operate because you can write all the risk assessments in the world, but unless your staff are understanding of and actively managing risk, all your paperwork means absolutely nothing. Despite this reality, the paperwork obsession remains a top priority for many organisations, but unless every activity is being run by switched on professionals who pro-actively manage risk within the organisation, then no matter how good your paperwork is, you’re exposed.
The practical reality is that you can write whatever you like in a risk assessment document but often, once it’s written, it’s quickly forgotten. It soon gathers dust and like vampire in the night, it never sees the light of day again, until a pile of fanged marked corpses prompt someone into action.
You simply can’t afford to place yourself or your staff in a situation where this is the standard operating procedure. The end result, if something does go wrong, is usually expressed through head scratching and befuddled proclamations, ‘Well, we wrote a risk assessment!’ However, there can’t be a disconnect between the documentation and the implementation. They must be reflective of each other.
One organisation I previously worked for were totally and utterly obsessed with written risk assessments. I was tasked with auditing their risk assessments and methodology. However, from the moment I started reading what they had in place, it became evident there was absolutely no connection between the activity and what had been written. Subsequently, it became perfectly obvious that nobody had actually read any of the paperwork, which left me wondering what they’d been doing. Not only did their pointless documentation have to be re-written from scratch, a significant process of change management was required to refocus the culture within the organisation to be one that was proactive in its assessment and management of risk.
Often the source of this problem is that many organisations don’t have people who truly understand risk management at the top. Just because someone has reached a leadership position, doesn’t mean he actually knows anything about management, least of all, risk management. Therefore, if you put someone in the situation where he is supposed to be managing risk, yet doesn’t understand risk beyond filing a written document, it’s little wonder that he’s focussed on paper pushing nonsense and not on organisational culture.
In this situation, when something goes wrong, it becomes all about blame and retribution. It’s not about discussing what was the root cause of an incident, it’s about finding scapegoats. This sort of approach is unhealthy and totally counter-productive. What an organisation needs to be able to do is sit down and openly discuss activities that involve risk and be prepared to debrief near misses and learn from each other’s knowledge and experience.
Good risk management procedures stem from this sort of open, honest and pro-active culture of risk managers within an organisation. If everything’s about retribution and blame, you create a culture that wants to cover up anything that doesn’t go 100% to plan. With this, you get a thin veneer giving the impression everything’s fine, yet scratch the surface and you’ll find what can be a toxic mix, priming itself for a significant failure.
To avoid this, there has to be that open and honest conversation about risk, about contingency planning and about response and mitigation. It’s important to have someone at the top setting the tone and facilitating the culture within an organisation to ensure you have a team of proactive risk managers.
Ultimately, documentation is only a tiny part of how your organisation should be assessing and managing risk. The remainder comes down to the professionalism, experience and team work of your staff to ensure that every activity is being run safely and effectively. Once you’re operating with this cultural mindset and have a team of pro-active risk managers, the paperwork takes care of itself.

Nothing Like 25 Years Without Being Informed!

School Bus Emergency Door

To really understand how incompetent some people are when it comes to reporting incidents, you need only look at my old school. Wait, no… not the one of which you’re thinking! Let’s go back further to when I was in a Government high school myself.
It was the 90s, an almost lost decade when the great fashion styles of the 80s were now dead and replaced with slightly more conservative hair cuts and mobile phones that came in a bag. Yes that’s right, A mobile didn’t fit in your pocket. It came in its own bag. They were enormous! I remember that everyone thought that people who carried their own bag phone around, must have been either super important, or a complete tosser! In reality, it was the latter, but I digress.
Whilst I prefer not to talk about my high school experience, because it could lead to far too many expletives being used in every sentence, the remarkable thing about life is the fact that we can learn some great lessons from complete idiots. Just take a look at the Darwin Awards, which is a great testament to this fact. Sadly, I don’t have another contender for the Darwin Awards on this occasion. However, there’s no shortage of idiots involved, so for those of you involved in risk management, this is what not to do when your school bus gets hit by a semi-trailer.
Now it wouldn’t be fair to talk about the day trip to Narrabri without putting it into some sort of context. Why were we travelling two hours from Tamworth in Northern NSW to Narrabri just to have an argument?
For me, this was one of the most exciting days of the year. It was the regional debating championships and for one, it had me out of school for the day, which was always preferable. More importantly, it was one of the best debating competitions around. Sadly, the English staff who were supposedly running debating, didn’t share this view. Since it wasn’t Rugby League, the rest of the school had a dim view of it as well. The only time I’d actually been to Narrabri for the championship was two years before when I was in Year 7 and we did very well, getting into the finals but coming runner up at the end of the day. The next year however, one of the students slept in, and so rather than leaving one student behind, the stupid teacher waited and did nothing for an hour and a half, until the student got on the bus. We arrived massively late and forfeited every single debate. Yet another stellar moment for the English Department.
However, I’ll leave it at the fact that the English Department and I did not get along. There was some unpleasantness. I remember in Year 12, I was excluded from the debating team for apparently being too argumentative… but that’s a much longer story for another time!
Back to the matter at hand. I was thrilled to be heading off to Narrabri for the day of debating. It was a knock out impromptu debating competition, which I loved and given the previous year’s mess, I was eagerly anticipating getting there and at least competing in the first round!
Despite the fact that it had been raining overnight and drizzling that morning, all was going well. I was picked up on time in town, which was a pleasant surprise. Jumping on the bus, I found a seat right in the middle of the mini-bus on the driver’s side. It was on the outskirts of Tamworth when I first noticed the bus seemed to be all over the road. It was raining more heavily and the driver, one of the illustrious English teachers, had managed to slip the bus off the road twice into the soft verge at the side of the bitumen. On the second slip I banged my knee hard into the seat in front of me. “What an idiot,” I thought. (I was thinking worse than idiot… but I’m keeping this PG). This year we were in no hurry, but the teacher seemed hell-bent on racing the whole way there.
Another twenty minutes on and with a few more bumpy shunts all over the road, we were close to Gunnedah and approaching a narrow bridge over the Mooki River. It was raining. We seemed to be speeding in a bus that had already slipped off the road a number of times and now were approaching the narrow wooden Mooki Bridge. I glanced up to see a semi-trailer heading in our direction. It was half way over the bridge. Then everything suddenly slowed down.
I don’t remember hearing the screech of the wheels, but at some point the teacher had slammed on the brakes, the wheels had locked up and the bus spun around in slow motion 90 degrees. We were now sliding sideways straight along the road, completely out of control. Out my window, a massive bull-bar- covered grill was coming straight for me. Nothing profound was going through my mind as I grabbed to push my back hard into my seat and braced myself against the seat in front. There were no seat belts and we were about to be T- boned in the middle of the bus.
It was the quick thinking of the truck driver who saved us that day. As I watched helplessly from my seat, the massive bull-bar came closer and closer. Suddenly the rig of the semi-trailer veered sharply left. It’s wheels shifted and rumbled off the side of the road. The driver was now trying to turn hard left and the bull bar was facing slightly away from me, but with the truck close to us now and with nowhere left to go, I held my breath. The bus was deathly silent.
The most frightful, deafening sound of crunching metal smashed the silence. The semi had clipped the rear of the mini bus. The side windows shattered. Glass sprayed slowly through the air like a thousand diamonds hovering slightly, as the bus spun violently, before arcing to the floor. Glancing back, I saw the semi-trailer roll onto its side and into a ditch next to the road. We came to an abrupt stop. I sat there stunned as everything seemed to return back to normal speed. “I’ve got to get off the bus,” I thought. “What if it explodes?”
With my ears ringing, I could now hear screaming and shouting throughout the bus. All I could think of was what if another truck comes along and hits us? I scrambled off the bus. It sat awkwardly, still halfway across the road. The massive semi-trailer lay motionless.
Despite our teacher being a massive tosser, unfortunately he didn’t have an enormous bag phone, so we had to call emergency services 90s style!!
I ran across the old narrow wooden bridge to the other side. Sure enough, another truck was picking up speed as it headed out of town. Standing in the middle of the road I flagged him down. I can’t remember what I said, or even if it made any sense, but with wreckage strewn all over the road ahead, it was fairly obvious we needed help. The truck driver got on the CB radio and soon we could hear the sounds and see the flashing lights of the ambulance and police racing towards us.
A couple of students were still on the bus. The teacher had run off to the other vehicle and not bothered to check on any of us, despite the common sense rule of check your students! Given the fact he should have owned a bag phone, this wasn’t surprising in any way. As in every movie climax after the life or death conflict has been resolved, the flashing lights and uniforms around us seemed to create a sense of calm. I think I was too stunned and possibly concussed at this point to really be feeling anything. Although, I remember thinking, “We’re going to be late for the debate again!”
A couple of students and the truck driver, who in his superb efforts to save us had broken his leg, were loaded into ambulances and rushed off to hospital. We were loaded back on the bus which still could be moved and driven to hospital. To say I was reluctant to board the bus was an understatement, especially with that guy at the wheel, who in my opinion was completely responsible for everything that had just happened. However, the police determined the bus could be driven only about 4 km to Gunnedah Hospital.
We sat around and waited to be seen in hospital. One after another, a doctor checked us. My knee was sore and I felt exhausted. Otherwise, I was fine. For us, the ordeal was pretty much over, but for everyone else it had only just begun!
Thanks to modern forms of communication at that time (the CB radio), which could be easily listened into by anyone, the 8.30am local ABC radio news had already broadcast the accident informing all the northwest that  “a bus from a Tamworth school had crashed.”
Panic arose for some primary school parents whose children had left that morning for Canberra.  The 9am news stated, “The bus was not from Oxley Vale School.”
The phones at our school, those ones that plug into the wall, went into meltdown, as only a tiny bit of information was released on the radio. By 11am, the school was named. It didn’t say that it was the debating team, a significant point by which most parents would have known it didn’t involve their son. Everyone, however, had assumed it was a football team or some other excursion and thus many parents were trying to ring one phone number all at once. The parents with children in the debating team had also found out and couldn’t contact the school due to the phones being engaged.
If there’s one thing you should do in the event of a critical incident, it’s inform the parents of those involved as soon as you can! Release a detailed statement to the rest of the school community based on clear facts and in line with the needs of the community. Failing to do so, creates more problems. It creates panic and uncertainty and parents will fill in all the blanks you’ve left for them with their imagination. Soon parent imagination can turn into pseudo facts and you will have an even bigger mess on your hands. It’s hard to respond to that and much harder from which to recover.
Rather than using another phone line to call the parents of the students who were involved, the school did nothing. Yes, that’s right! Nothing at all! The hopeless response to this major incident is probably one of the reasons why I believe risk and incident management is so important. Seeing people do something so badly, usually prompts me to do the opposite and make sure it’s done properly.
A teacher at the school told my older brothers and gave them the tiny bit of information that was heard on the radio. One brother rang our mother at her work with the words, “The bus has crashed, but David is all right.” She in turn rang our father at his work and he kept dialling the school number to see if he should drive to Gunnedah or where.
The school sent a teacher in another bus to come and pick everyone up from Gunnedah Hospital. There wasn’t anything wrong with this in itself. We were collected at the hospital, driven back to Tamworth and dropped off either at or near home or at a parent’s work with no meet and greet to the parents, nor any sort of handover. I was the only student with immediate parent contact. One boy was set down in town and had to wait about three hours for his regular school bus to take him home to Manilla.
A number of students were dropped off at empty houses. After almost being killed in a horrible collision with a truck, the teacher somehow thought that dropping shaken teenagers off at an empty house was an appropriate thing to do! Even the most useless and incompetent teacher should have known better than that! Perhaps the teacher who picked us up should have been carrying two bag phones. As he was head of welfare for the school, it’s rather ironic that he appeared to know nothing about student welfare, but again that’s my opinion and a much longer story for another time in regards to what I believe was his incompetence and inability to fulfil an important role.
The idea that it was ok to drop students off at home when nobody was there after a traumatic road collision was stupid even for the 1990s. I remember being dropped off at Tamworth West Primary School where my mother was teaching her Year 4 class. I wandered in, still possibly concussed and remember lying down somewhere in the classroom and falling asleep. Mum sensibly refused to take me home in her lunch break.
What should have happened? All students should have been driven back to school. No one should have been left alone. Day boys could have been left under Matron’s watchful eye, until their parents arrived to collect them. Boarders could have been supervised by Matron and/or their dormitory master.
From an incident response and management point of view, the lack of communication was pathetic. It might have been a lack of training, a lack of response planning, or just the fact that I went to a school that appeared to be run ineffectively. The bottom line was that there was no plan in place if something went wrong. It was evident that everyone was simply making things up as they went.
Whilst critical incidents are fluid in nature and you may need to respond in an inter-active way to contain the initial situation, there is absolutely no reason why any school or organisation can’t have clear actionable steps in place to be able to respond quickly and effectively to a major incident. It’s vital that you inform parents and if needed, draw on resources in the wider community, such as local radio.
Over the past 25 years, at no time did anyone from the school contact my parents to let them know what happened! At no point was the incident ever debriefed! At no point did anyone ask about the debating! Two years in a row, we’d forfeited the most awesome competition in the region and to this date, the school still hasn’t officially told anyone that the bus crash actually occurred.
The Principal suddenly left the school and the questions about the crash, that parents asked at the P & C meeting, were unanswered.
Despite all of this, I learnt some very important lessons as to what not to do in a situation like this. One thing it highlights though, is the fact that for all the carry on I’ve seen over the years from people who don’t understand risk management and incident management, the fact remains, being on the road with students is one of the highest risk factors possible.
Driving to the conditions, avoiding peak periods of traffic and having a fatigue management policy and procedure in place is vital to reduce this transport risk that’s part of every trip away from school.
Let’s put this back in context. We were going to a debating competition!!! Sounds very low risk and not even worth doing a risk assessment on, yet had the truck driver not reacted the way he did, our bus would have been cut in two and a few more sun-bleached crosses would have stood scattered at the side of the road, lovingly surrounded by flowers, tended only, in decreasing frequency, by the broken families who were never told what really happened that day.