DreamWorld and the importance of training records.

[old man emu]

I sent to following to the organisations for whom I conduct management audits. I think the message is well worth posting here.

 

DreamWorld and the Importance of Records of Training

 

There is a Coronial Inquest being conducted at the moment in Queensland into the deaths of four people on a thrill ride at the DreamWorld theme park in 2016. The evidence already given to the Inquest should be ringing alarm bells and waving warning flags in the face of every organisation that has a legal responsibility to safeguard the safety of persons (Work, Health & Safety) and the environment.

 

The evidence so far is pointing to a corporate culture in which training (in this case, of safety related matters) is haphazard. There also appears to have been no documentation of the content of the training topics, nor of the successful completion of the training by recipients.

 

Earlier, a former Dreamworld employee described witnessing an incident in which four rafts collided on the Thunder River Rapids ride over 15 years before the tragedy on the same attraction in 2016. Joe Stenning was beginning a shift as a deckhand on the ride in January 2001 when the empty rafts collided, forcing one to flip over. Mr Stenning said he couldn’t recall if he underwent any emergency training or retraining on the Thunder River Rapids ride after the incident.

 

The Inquest heard Dreamworld staff had openly discussed among themselves their desire to undertake emergency drills, a Queensland Inquest has heard. Training and compliance officer Amy Crisp told the court that emergency training was something staff were keen to receive.

 

“It was something that as operators we talked about wanting,” Ms Crisp told the Inquest. “It was just in conversation with other operators that there was an operator that used to work at Movie World and at Movie World they did things like this.” Ms Crisp is just one of several staff to tell the Inquest that not only had she not undertaken any emergency drills at Dreamworld she also had no CPR or first-aid training.

 

What has this got to do with Environmental Management?

 

Quite clearly this Inquest has brought into the open the fact that, if an incident occurs that gives rise to an inquiry with legal ramifications, either criminal or civil, then the inquiry will place a great deal of reliance on documentation of procedures and records that show that persons required to carry out those procedures have been adequately trained (including exhibiting their competence in following the procedure).

 

During audits conducted by Shark Consulting, attention is paid to the existence of this documentation, and related records. At previous audits, the focus has been on the practicalities of environmental risk management, and not so much on the documentation and records. This previous focus has proved effective for most client organisations.

 

Commencing with the 2018/2019 triennial independent audits, the focus will be on documentation, training and records. Not because these things are niceties, but because these things are an organisation’s insurance policy if it is drawn into an inquiry having legal ramifications.

 

 

[turboplanner]

Like speed cameras the documents are definitive.

 

How much easier would it have been to have given the young girl a document which stated: "to stop the ride, press this button".

 

 

[facthunter]

Aviation is a world leader in many facets of training and risk management, particularly multi crew and having back ups for control and functions. (More Fail safe situations). We are not perfect, but you can see the lack of organization in this matter clearly. Nev

 

 

[Yenn]

There is some similarity between Dreamworld and our aviation, but it is apparent that Dreamworld was not too keen on spending money on training. Nobody seemed to know what the emergency stop button was supposed to do, or if they should use it.

 

Our training is hopefully much better and is indeed heading to the point where having the paperwork done will supposedly eliminate accidents.

 

In real life the sensible course is somewhere between paper work and just getting the job done.

 

I managed construction in what was considered a dangerous job for years and didn't have a single piece of paperwork, concerning training. Didn't have a single hospitalisation injury in 11 years.

 

 

[Birdseye]

Like speed cameras the documents are definitive.>SNIP< .

Poor (but oddly fortuitous) choice of analogy, as WA Police have had to hand back cash and cancels demerits due to defective cameras. The fortuitously relevant aspect is that that they were aware of the problem at least last February, but elected to continue using them......So its training *and* maintenance records that are critical.

 

 

[jetjr]

The recording of training and clear training syllabus makes sure nothing is missed in bulk training

 

Id say this is the reason behind RAA L1 exercise

 

 

[WayneL]

I couldn't help thinking, while listening to the news reports on the hearing why their training did not include practical training in actually getting staff to hit the stop buttons etc to observe what happens. They could turn the pumps off and have staff watch what happens to the tubes on the conveyer chain, explain what could happen and have the staff practice using the emergency stop controls to gain confidence in using it without a second thought. With the emphasis on staff immediately shutting the ride down if anything seems amiss, without fear of punishment.

 

Wayne

 

 

[facthunter]

Training cannot presume to be achieved without some method of assessing it's thoroughness.... The teacher has to be taught how to teach. Going through the motions is not enough.. Actions must be in response to real situations and the effect known. and observed. to occur. Nev

 

 

[turboplanner]

I couldn't help thinking, while listening to the news reports on the hearing why their training did not include practical training in actually getting staff to hit the stop buttons etc to observe what happens. They could turn the pumps off and have staff watch what happens to the tubes on the conveyer chain, explain what could happen and have the staff practice using the emergency stop controls to gain confidence in using it without a second thought. With the emphasis on staff immediately shutting the ride down if anything seems amiss, without fear of punishment.Wayne

If I remember correctly on the record that the girl was shown the stop button but told not to worry about it because she would never have to use it; there was also another stop button which cold have been used. It's eerily similar to the people who point to the RA notice on the instrument panel and tell their passenger not to worry about it, nothing's going to happen.

 

 

[winsor68]

I sent to following to the organisations for whom I conduct management audits. I think the message is well worth posting here.

DreamWorld and the Importance of Records of Training

 

There is a Coronial Inquest being conducted at the moment in Queensland into the deaths of four people on a thrill ride at the DreamWorld theme park in 2016. The evidence already given to the Inquest should be ringing alarm bells and waving warning flags in the face of every organisation that has a legal responsibility to safeguard the safety of persons (Work, Health & Safety) and the environment.

 

The evidence so far is pointing to a corporate culture in which training (in this case, of safety related matters) is haphazard. There also appears to have been no documentation of the content of the training topics, nor of the successful completion of the training by recipients.

 

Earlier, a former Dreamworld employee described witnessing an incident in which four rafts collided on the Thunder River Rapids ride over 15 years before the tragedy on the same attraction in 2016. Joe Stenning was beginning a shift as a deckhand on the ride in January 2001 when the empty rafts collided, forcing one to flip over. Mr Stenning said he couldn’t recall if he underwent any emergency training or retraining on the Thunder River Rapids ride after the incident.

 

The Inquest heard Dreamworld staff had openly discussed among themselves their desire to undertake emergency drills, a Queensland Inquest has heard. Training and compliance officer Amy Crisp told the court that emergency training was something staff were keen to receive.

 

“It was something that as operators we talked about wanting,” Ms Crisp told the Inquest. “It was just in conversation with other operators that there was an operator that used to work at Movie World and at Movie World they did things like this.” Ms Crisp is just one of several staff to tell the Inquest that not only had she not undertaken any emergency drills at Dreamworld she also had no CPR or first-aid training.

 

What has this got to do with Environmental Management?

 

Quite clearly this Inquest has brought into the open the fact that, if an incident occurs that gives rise to an inquiry with legal ramifications, either criminal or civil, then the inquiry will place a great deal of reliance on documentation of procedures and records that show that persons required to carry out those procedures have been adequately trained (including exhibiting their competence in following the procedure).

 

During audits conducted by Shark Consulting, attention is paid to the existence of this documentation, and related records. At previous audits, the focus has been on the practicalities of environmental risk management, and not so much on the documentation and records. This previous focus has proved effective for most client organisations.

 

Commencing with the 2018/2019 triennial independent audits, the focus will be on documentation, training and records. Not because these things are niceties, but because these things are an organisation’s insurance policy if it is drawn into an inquiry having legal ramifications.

Ships everywhere these days in the "corporate" world Emu. Didn't you know?

 

 

[old man emu]

Ships everywhere these days in the "corporate" world Emu. Didn't you know?

Can't work out what you mean.

 

 

[old man emu]

Work Health and Safety Act 2011; Part 2 Division 2 Section 19 (3) (f)

 

A person conducting a business or undertaking must ensure, so far as is reasonably practicable:

 

f) the provision of any information, training, instruction or supervision that is necessary to protect all persons from risks to their health and safety arising from work carried out as part of the conduct of the business or undertaking,

 

Work, Health and Safety Regulation 2017; Chapter 3 Part 3.2 General workplace management

 

Division 1 Information, training and instruction

 

39 Provision of information, training and instruction

 

(1) This clause applies for the purposes of section 19 of the Act to a person conducting a business or undertaking.

 

(2) The person must ensure that information, training and instruction provided to a worker is suitable and adequate having regard to:

 

(a) the nature of the work carried out by the worker, and

 

(b) the nature of the risks associated with the work at the time the information, training or instruction is provided, and

 

© the control measures implemented.

 

Maximum penalty: (a) in the case of an individual—$6,000, or

 

(b) in the case of a body corporate—$30,000.

 

(3) The person must ensure, so far as is reasonably practicable, that the information, training and instruction provided under this clause is provided in a way that is readily understandable by any person to whom it is provided.

 

Maximum penalty: (a) in the case of an individual—$6,000, or

 

(b) in the case of a body corporate—$30,000.

 

The Queensland WH&S Act and Regulations are the same as for NSW.

 

I'd say that DreamWorld is up for a minimum of $60,000.

 

But that was my point in advising my clients to document and record. How else can you prove "suitable and adequate" or "readily understandable"?

 

 

[facthunter]

ALL through my aviation career /experience I've constantly applied the TEST? How would this look at the INQUIRY? It injects a necessary bit of reality to the situation. Nev

 

 

[winsor68]

Documenting it seems to have become the goal of WH&S to the serious detriment of actual safety. I've seen it everywhere in the workplace today. We are fxxxxxd!

 

 

[kgwilson]

Training and testing the effectiveness of training is necessary to ensure that the trainee has fully understood and is capable of performing the task. Documentation is necessary to prove that the training actually took place and the trainee was able to perform the task. The documented evidence is in reality only required when the $hit hits the fan.

 

 

[farri]

A trainee may well have understood the training and demonstrated at the time of the training that they were competent in performing the task they were trained to do, however, in a real-life emergency situation where seconds can determine the outcome, for various reasons the trainee might not respond in the manner they were trained to respond! We see it so often in Air Crash Investigations.

 

Off topic...Why wasn`t the ride at Dreamworld designed with a safety device/s that would automatically shut the ride down?

 

Frank.

 

 

[old man emu]

A trainee may well have understood the training and demonstrated at the time of the training that they were competent in performing the task they were trained to do, however, in a real-life emergency situation where seconds can determine the outcome, for various reasons the trainee might not respond in the manner they were trained to respond! Frank.

That is quite correct, but there are two points in your comment.

 

1. The employer has the duty to provide clear and concise training to employees. Part of that training is having the trainee demonstrate competency in performing the task.

 

2. An individual is highly likely to be incompetent in carrying out a task in an emergency setting.

 

My point in sending a cautionary note to my clients is that, if they don't

 

1. Develop and document procedures for carrying out a task, and

 

2. Communicate the procedures to their employees, and

 

3. Ensure that the employees are competent, and remain competent in carrying out the task, and

 

4. Record the fact that the employees have been provided with training, and are deemed competent,

 

then if the poop hits the fan, the employer will be held responsible for any injuries suffered.

 

Regular review by employees of the procedures, including completing simulations, is the only way to maintain competency (remaining current). That's why batsmen and bowlers spend hours at the nets.

 

Off topic...Why wasn`t the ride at Dreamworld designed with a safety device/s that would automatically shut the ride down?Frank.

Yes it was, but the testimony suggests that the employees were not trained or competent in its use. This could have been a factor in the failure to respond, along with the emotional disruption caused by seeing the event unfold.

 

 

[farri]

My point in sending a cautionary note to my clients is that, if they don't1. Develop and document procedures for carrying out a task, and

2. Communicate the procedures to their employees, and

 

3. Ensure that the employees are competent, and remain competent in carrying out the task, and

 

4. Record the fact that the employees have been provided with training, and are deemed competent,

 

then if the poop hits the fan, the employer will be held responsible for any injuries suffered.

Yes! I understand that and thank you for your reply!

 

QUOTE="old man emu, post: 669249, member: 282"]Yes it was, but the testimony suggests that the employees were not trained or competent in its use. This could have been a factor in the failure to respond, along with the emotional disruption caused by seeing the event unfold.

 

Yes! I understand that also! but the fact that an employee had to activate an emergency device to stop the ride suggests to me that the ride wasn`t fitted with a safety device to automatically stop it without the need of the operator, therefore, the design of the ride contributed to the accident also.

 

Frank.

 

 

[facthunter]

The set up has a lot of powerful water pumps. It might not be easy to shut it down safely. Wasn't the lack of water part of the problem that directly caused the injuries/deaths? Nev

 

 

[APenNameAndThatA]

I sent to following to the organisations for whom I conduct management audits. I think the message is well worth posting here.

DreamWorld and the Importance of Records of Training

 

There is a Coronial Inquest being conducted at the moment in Queensland into the deaths of four people on a thrill ride at the DreamWorld theme park in 2016. The evidence already given to the Inquest should be ringing alarm bells and waving warning flags in the face of every organisation that has a legal responsibility to safeguard the safety of persons (Work, Health & Safety) and the environment.

 

The evidence so far is pointing to a corporate culture in which training (in this case, of safety related matters) is haphazard. There also appears to have been no documentation of the content of the training topics, nor of the successful completion of the training by recipients.

 

Earlier, a former Dreamworld employee described witnessing an incident in which four rafts collided on the Thunder River Rapids ride over 15 years before the tragedy on the same attraction in 2016. Joe Stenning was beginning a shift as a deckhand on the ride in January 2001 when the empty rafts collided, forcing one to flip over. Mr Stenning said he couldn’t recall if he underwent any emergency training or retraining on the Thunder River Rapids ride after the incident.

 

The Inquest heard Dreamworld staff had openly discussed among themselves their desire to undertake emergency drills, a Queensland Inquest has heard. Training and compliance officer Amy Crisp told the court that emergency training was something staff were keen to receive.

 

“It was something that as operators we talked about wanting,” Ms Crisp told the Inquest. “It was just in conversation with other operators that there was an operator that used to work at Movie World and at Movie World they did things like this.” Ms Crisp is just one of several staff to tell the Inquest that not only had she not undertaken any emergency drills at Dreamworld she also had no CPR or first-aid training.

 

What has this got to do with Environmental Management?

 

Quite clearly this Inquest has brought into the open the fact that, if an incident occurs that gives rise to an inquiry with legal ramifications, either criminal or civil, then the inquiry will place a great deal of reliance on documentation of procedures and records that show that persons required to carry out those procedures have been adequately trained (including exhibiting their competence in following the procedure).

 

During audits conducted by Shark Consulting, attention is paid to the existence of this documentation, and related records. At previous audits, the focus has been on the practicalities of environmental risk management, and not so much on the documentation and records. This previous focus has proved effective for most client organisations.

 

Commencing with the 2018/2019 triennial independent audits, the focus will be on documentation, training and records. Not because these things are niceties, but because these things are an organisation’s insurance policy if it is drawn into an inquiry having legal ramifications.

Did you have to sound so stilted, and use so many zombie nouns and unnecessary words? For example, "Quite clearly this inquest has brought into the open the fact that" could have been left out. Instead of "place a great deal of reliance [zombie noun] on", you could have said, "rely [verb] on". You are changing how you audit - which is humble and self-reflective - but the way you announced it made you sound pompous.

 

 

[winsor68]

Did you have to sound so stilted, and use so many zombie nouns and unnecessary words? For example, "Quite clearly this inquest has brought into the open the fact that" could have been left out. Instead of "place a great deal of reliance [zombie noun] on", you could have said, "rely [verb] on". You are changing how you audit - which is humble and self-reflective - but the way you announced it made you sound pompous.

Funny thing is....how you can bet that Dreamworld passed all it's audits!!!

 

 

[old man emu]

Did you have to sound so stilted, and use so many zombie nouns and unnecessary words? .

What style do you want me to adopt when I am writing to business owners? Shud eye youse leetspeak?

 

 

[APenNameAndThatA]

What style do you want me to adopt when I am writing to business owners? Shud eye youse leetspeak?

Um, you could be less stilted, use fewer zombie nouns and fewer unnecessary words?

 

You could ask, "What writing style do you think business owners would prefer?"

 

The sentence you wrote has you doing two things: adopting a style and writing. The sentence only needs to have you doing one thing: writing in a style. The phrase "the fact that" can usually be removed. You can direct the reader to something without telling them that the thing is a thing: one thing, not two.

 

 

[Yenn]

OME I like your style. Your post No 17 should be used as a guide to how to write regs, by CASA. We would know then what they mean, rather than have to re read six times and still be unsure.

 

As far as passing audits, it is all a matter of ticking boxes and nobody is supposed to fail. In my last few years at work I found that if I failed the computer based safety questionaires, I was still given the "whatever" card to let me go onto industrial sites.

 

 

[johnm]

Could it be that the design of the ride was not safe when a failure occured ........... it was not failsafe

 

Could it be the ride did not have a redundancy - training is one thing but if a trained person had to push a button to stop 4 people being killed ............ that seems to me to be deficient design