|
|
1 | (6) |
|
|
6 | (1) |
|
2 Lessons Learned and Two Faces of Accident Case Study |
|
|
7 | (14) |
|
2.1 Looking Backwards with Compassion, Forwards with Vigilance. Interpreting Accounts of Past Tragedies |
|
|
7 | (2) |
|
2.2 All Accident Reports Are Partial, and All Causal Accounts Are Attributions, But OE Prevention Is a Pragmatic Search for the Most Useful Insights Available |
|
|
9 | (3) |
|
2.3 The Contribution of Coronial and Other Court Findings to OE Fatality Prevention |
|
|
12 | (1) |
|
2.4 The Role of Counterfactual Reasoning in OE Fatality Prevention |
|
|
13 | (2) |
|
2.5 The Nature of Case-Based OE Fatality Prevention Knowledge |
|
|
15 | (4) |
|
2.6 Learning from OE Fatal Incident Cases |
|
|
19 | (2) |
|
|
19 | (2) |
|
3 Strict Aversion to Fatal Incidents as a Standard |
|
|
21 | (34) |
|
3.1 OE Fatality Prevention Requires a Self-Imposed Standard of "Strict Aversion" to Preventable Deaths |
|
|
21 | (4) |
|
3.2 Reviewing an OE Program Against a Standard of Strict Aversion to Fatal Incidents, and What Action Might Be Required |
|
|
25 | (2) |
|
3.3 Failure to Adopt Strict Aversion in Practice - The Death of Laura McDairmant |
|
|
27 | (2) |
|
3.4 Failure to Adopt Strict Aversion in Practice - The Death of Catherine Peters |
|
|
29 | (2) |
|
3.5 Failure to Adopt Strict Aversion in Practice - Two Bear Attacks in 2011 |
|
|
31 | (11) |
|
3.6 Strict Aversion Defined by Lessons Learned |
|
|
42 | (1) |
|
3.7 Alternatives to "Strict Aversion": Community Responses, Legal Consequences, and Standards of Care in OE |
|
|
43 | (1) |
|
3.8 What Would the Press Say? What Would a Coroner Say? What Would a Bereaved Parent Say? |
|
|
44 | (1) |
|
3.9 Why Strict Aversion, Rather Than Acceptable Risk, Is Likely to Be Applied to OE Fatality Judgments |
|
|
45 | (2) |
|
3.10 Compliance with Published Standards as an Alternative to Strict Aversion |
|
|
47 | (5) |
|
3.11 Taking All Reasonable Steps to Prevent Any Fatality in OE |
|
|
52 | (3) |
|
|
52 | (3) |
|
4 Multiple Fatality Incidents on School and Youth Group Camps and Excursions - Water-Based Activities: Lessons for Prevention |
|
|
55 | (46) |
|
|
55 | (1) |
|
4.2 Preventability of Immersion Deaths |
|
|
55 | (6) |
|
|
61 | (8) |
|
4.4 Open Water Catastrophic Incidents |
|
|
69 | (9) |
|
4.5 Ocean Shore Incidents |
|
|
78 | (5) |
|
|
83 | (6) |
|
4.7 Catastrophic Rescue Attempts |
|
|
89 | (3) |
|
4.8 Preventing OE Water Catastrophes |
|
|
92 | (9) |
|
|
95 | (6) |
|
5 School and Youth Group Camp and Excursion Catastrophic Events on Land: Lessons for Prevention |
|
|
101 | (26) |
|
|
101 | (3) |
|
5.2 Transport to and from Venues |
|
|
104 | (4) |
|
5.3 Fire, Structural Collapse, and Intentional Deaths |
|
|
108 | (3) |
|
5.4 Knowable Environmental Hazards |
|
|
111 | (1) |
|
|
112 | (2) |
|
|
114 | (4) |
|
5.7 Weather Forecasts and Observation Data |
|
|
118 | (1) |
|
5.8 Other Knowable Environmental Hazards |
|
|
118 | (1) |
|
5.9 Concluding Discussion |
|
|
119 | (8) |
|
|
121 | (6) |
|
6 Single Fatalities on School or Youth Group Camps and Excursions: Lessons for Prevention from Australia and the UK |
|
|
127 | (72) |
|
|
127 | (2) |
|
|
129 | (12) |
|
|
141 | (2) |
|
6.4 Falling Trees or Branches |
|
|
143 | (2) |
|
|
145 | (2) |
|
|
147 | (1) |
|
6.7 Australian OE Immersion Deaths - Dams, Lakes and Pools |
|
|
148 | (15) |
|
6.8 Australian and Selected UK Immersion Deaths, Moving Water |
|
|
163 | (12) |
|
6.9 Hyperthermia, Hypothermia and Lightning Strikes |
|
|
175 | (5) |
|
6.10 Animal Related Deaths |
|
|
180 | (3) |
|
6.11 Murder, Suicide, Transportation-Related Deaths, Deaths from Natural Causes, Anaphylaxis and Fire |
|
|
183 | (16) |
|
|
190 | (9) |
|
7 OE Fatality Prevention at an Organisational Level |
|
|
199 | (32) |
|
|
199 | (2) |
|
7.2 OE Fatal Incidents in Organisational Contexts |
|
|
201 | (2) |
|
7.3 Locating OE Fatality Prevention in Wider Social and Cultural Circumstances |
|
|
203 | (1) |
|
7.4 OE Fatality Prevention, Even in Large Organisations, Always Comes Down to the "Sharp End", Which Is the Care of Individuals in Specific Situations |
|
|
204 | (3) |
|
7.5 How Applicable Is Industrial Safety to OE Fatality Prevention? |
|
|
207 | (3) |
|
7.6 How Applicable Is Structuralist "Systems Thinking" to OE Fatality Prevention? |
|
|
210 | (10) |
|
7.7 OE Fatality Prevention and Organisational Risk Management |
|
|
220 | (5) |
|
7.8 Evaluating OE Fatality Prevention in Organisational Contexts |
|
|
225 | (6) |
|
|
226 | (5) |
|
8 Preventing Fatal Incidents |
|
|
231 | |
|
8.1 OE Fatality Prevention Requires Specific Expertise and Knowledge |
|
|
231 | (3) |
|
8.2 OE Fatality Prevention Requires Specific Focus |
|
|
234 | (2) |
|
8.3 Case-Based Fatality Prevention Establishes What Organisational, Regulatory, or Other Managerial Responses Must Achieve, But Not How |
|
|
236 | (1) |
|
8.4 Failures to Pursue or Share Lessons from OE Tragedies |
|
|
237 | (3) |
|
|
240 | |
|
|
240 | |