Review of risk management and safety in the adventure and outdoor commercial sectors in New Zealand 2009/10 - Final report

VIII. APPENDICES

Appendix 1: Review terms of reference

Background

On 16 September 2009, the Prime Minister wrote to the Minister of Labour expressing concern about a number of incidents in the adventure and outdoor commercial sectors, including the tragic death of young British backpacker Emily Jordan. The Prime Minister noted public concerns about the various regulatory regimes governing these activities in New Zealand.

The Prime Minister advised the Minister of Labour that he would like the Department of Labour to lead a cross-departmental group to investigate and report back on the situation and ways of improving risk management and safety in the sector. He requested a report on the group's findings and suggestions from the Minister on any changes she considers necessary to improve risk management and safety in the sector.

Purpose

The purpose of the review is to investigate the current situation and ways of improving risk management and safety in the adventure and outdoor commercial sectors in New Zealand and to report to the Minister of Labour with suggestions for changes to improve risk management and safety in those sectors.

Scope

The following has been determined to be within, or outside of, the scope of the review:

In scope:	Where an adventure or outdoor commercial service is being sold or provided; agency resources; jurisdictional issues.
Out of scope:	Activities not paid for (non-commercial) / purely recreational.

Definition

For the purposes of the review, 'adventure and outdoor commercial sectors' has been defined as meaning all recreational-type activities offered on a fee-for-service basis that carry heightened inherent risks that must be managed.

The review will include activities carried out indoors (such as indoor rock climbing) where those activities carry inherent risks of a similar nature to activities conducted outdoors.

While the definition may capture some activities not generally considered as 'adventure and outdoor' activities, the review will determine the focus of its next activities when the stock-take has been completed.

Review structure

Governance

The Group Manager Workplace, Department of Labour, will be the sponsor for the review. The Manager, Workplace Health and Safety Policy, Department of Labour, will be the responsible manager. A Senior Advisor Workplace Health and Safety Policy, Department of Labour, will be the project manager.

A steering group has been established to assist the Group Manager in his role as sponsor and comprises the following internal and external members:

Name	Title	Organisation
Craig Armitage	Group Manager, Workplace Policy (Chair)	Department of Labour
Paul Barker	Chief Advisor, Workplace Policy	Department of Labour
Glen-Marie Burns	Manager - Aviation & Security Sector	Ministry of Transport
Ray Salter	General Manager	Ministry of Tourism
Graeme Harris	General Manager Personnel Licensing & Aviation Services	Civil Aviation Authority
Geoff Ensor	Advocacy Manager	Tourism Industry Association NZ
Tim Cossar	Chief Executive	Tourism Industry Association NZ
Evan Freshwater	Relationship Manager	Tourism Industry Association NZ
Catherine Taylor	Chief Executive and Director	Maritime New Zealand
Lindsay Sturt	General Manager Strategy and Communications	Maritime New Zealand
Ray Campbell	Acting Manager Public Safety/Workplace Safety	ACC
Helen Gilbert	Corporate Planning Manager, Community and Strategy, Taupo District Council	(on behalf of) Local Government New Zealand

Project working group

A project working group has been established and comprises the following internal and external members:

Name	Title	Organisation
David Mulholland	Senior Policy Advisor (Chair)	Department of Labour
Bryan Williams	Senior Advisor Operational Policy (Sector)	Department of Labour
Tim Frank	Advisor	Ministry of Transport
Mark Walter	Policy Advisor	Ministry of Tourism
Graeme Harris	General Manager Personnel Licensing & Aviation Services	Civil Aviation Authority
Liam Brennan	Strategic Advisor Safety	Maritime New Zealand
Geoff Ensor	Advocacy Manager	Tourism Industry Association NZ
Tim Cossar	Chief Executive	Tourism Industry Association NZ
Evan Freshwater	Relationship Manager	Tourism Industry Association NZ
Malcolm Francis	Team Manager Injury Prevention	ACC
Paul Chaplow	General Manager	Outdoors New Zealand
Jamie Dale	Total Quality Manager, Strategic Development, Taupo District Council	(on behalf of) Local Government New Zealand
Mike Davies	Senior Technical Support Officer Research and Development Group	Department of Conservation
Nicola Chapple	Senior Policy Advisor	Department of Labour
Ross Clapcott	Chief Advisor	Ministry of Tourism

External reference group

An external reference group of key stakeholders will be drawn from the sector according to the advice of the governance group.

Process

The review is being undertaken in two phases:

Phase I - Scoping and establishing the knowledge base (21 September - 29 January 2010)

Phase I of the review will include:

Forming governance and working groups to lead and administer the review
Forming an external reference group of key stakeholders
Developing terms of reference that will include indicative deliverables and timing
Developing a communications strategy
Developing a project plan
Developing a sector engagement plan
Undertaking a stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand. This will include:
- The activities / types of activity included in the sector review
- The number of operators in the sector
- What regulations apply to them
- Agency jurisdictions and any jurisdictional issues
- Any controls for entry into the sector/starting the activities, or gaps at the front end
- Any education of tourists and other service users
- Whether there are any standards, guidelines (including voluntary and sector-driven guidelines), licensing regimes or registration systems that apply
- Whether there are any auditing, monitoring, quality assurance systems that apply
- The degree of injury reporting
- Any data on accidents by type of activity, incident reports, serious harm and fatalities and investigations undertaken
- Who has the authority to close an operation down and nature of that authority
- Current work being undertaken for regulation, quality assurance, etc.
Undertaking a stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors internationally, including work underway to improve those provisions (e.g. international standards, regulations, licensing regimes)
Undertaking consultation with reference group members
Undertaking consultation with operators, other peak bodies and other stakeholders in the adventure and outdoor commercial sectors for their views on the current situation and ways of improving risk management and safety in the sector. This may involve questionnaires, key informant interviews, focus groups and/or calling for submissions either directly from operators and stakeholders or through their representative groups
An initial review of findings from the stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand and the consultation, identifying any urgent issues that need to be addressed.

Phase II - Analysis, problem definition and reporting (1 February to 31 May 2010)

Phase II of the review will include:

Undertaking a gap analysis of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand
Analysis of findings from the stock-takes, gap analysis and consultation
Problem definition
Developing options for ways of improving risk management and safety in the sector and reporting back to the Minister of Labour with recommendations.

Indicative deliverables and timing

The responsible manager will provide regular updates to the sponsor, governance group and Minister of Labour, plus four formal reports as follows:

1. A stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand by 29 January 2010

2. A stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors internationally, including work underway to improve those provisions by 29 January 2010

3. A report on consultation by 29 January 2010

4. A final report for the Minister of Labour with options and recommendations by 31 May 2010.

Appendix 2: Methodology

Scoping and establishment

The Department formed a steering group to assist the Deputy Secretary, Workplace, in his role as sponsor of the review. The group included senior officials from a range of government departments and Crown entities, plus representatives from the Tourism Industry Association New Zealand and, initially, QLDC on behalf of LGNZ. A representative from Taupo District Council on behalf of LGNZ later replaced the representative from QLDC. A list of governance group member agencies is provided in the terms of reference for the review (see Appendix 1).

A working group was established to support the governance group and the Department in conducting the review. It was also composed of officials from a range of government departments and Crown entities, plus representatives from the Tourism Industry Association New Zealand, Outdoors New Zealand and, again initially, from QLDC on behalf of LGNZ (later changed to Taupo District Council). A list of working group member agencies is provided in the terms of reference for the review (Appendix 1).

A 67-member 'virtual' external reference group of people and organisations with relevant expertise, and/or representing particular parts of the adventure and outdoor commercial sectors, was drawn from the sectors based on advice from the governance and working groups. Members were drawn from:

Organisations or groups representing a number of adventure and outdoor commercial sector operators
Adventure and outdoor commercial sector operators
Academic researchers studying relevant aspects of the sector
Industry training organisations, standard setting organisations and educational bodies
Auditing, monitoring and quality assurance bodies
Any relevant central or local government agencies not represented on the governance or working groups
Other relevant experts as determined by the governance group.

Terms of reference were established that laid out a two-phase process for the review (see Appendix 1). The first phase included the following deliverables:

A stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand
A stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors internationally
Consultation with reference group members, operators, other peak bodies and other stakeholders in the adventure and outdoor commercial sectors (plus a report on the consultation)
An initial review of findings from the stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand and the consultation, identifying any urgent issues that need to be addressed.

The range of enquiry for the review was then fully scoped and defined.

For the purposes of the review, 'adventure and outdoor commercial sectors' was defined as meaning all recreational-type activities offered on a fee for service basis that carry heightened inherent risks that must be managed. Adventure or outdoor commercial services that are sold or provided, and agency resources and jurisdictional issues were determined to be within the scope of the review. Activities not paid for (non-commercial) and that are purely recreational were determined to be out of scope. Additionally, the governance group for the review decided that hire of equipment would not be part of the primary focus of the review, but that this might be reassessed if review findings suggested it would be appropriate.

When considering an appropriate definition for the adventure and outdoor commercial sectors, the governance group considered a range of definitions of adventure tourism, both nationally and internationally. It was agreed that the scope and definition included activities carried out indoors (such as indoor rock climbing) where those activities carry inherent risks of a similar nature to activities conducted outdoors. It was acknowledged and agreed that while a close analysis of this definition may capture activities not generally considered as 'adventure and outdoor' activities, the review would determine the focus of its next activities once a stock-take of the sector was completed.

The working group then moved to identify the main adventure and outdoor commercial sector activities that occurred in New Zealand that would be covered by the review. Forty-four activities were identified and were considered by the review.

The second phase of the review included:

Undertaking a high level gap analysis of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand
Analysis of findings from the stock-takes, gap analysis and consultation
Problem definition
Developing options for ways of improving risk management and safety in the sector and reporting back to the Minister with recommendations.

The stock-takes

The review team undertook a stock-take of risk management and safety provisions that applied to the adventure and outdoor commercial sectors in New Zealand. This was undertaken to gather information on:

The activities/types of activity included in the review
The number of operators in the sector
Participation levels
What regulations apply to operators
Agency jurisdictions and any jurisdictional issues
Any controls for entry into the sector
Any education of visitors and other service users
Whether there are any standards, guidelines (including voluntary and sector-driven guidelines), licensing regimes or registration systems that apply
Whether there are any auditing, monitoring, quality assurance systems that apply
The degree of injury reporting
Any data on accidents by type of activity, incident reports, serious harm and fatalities and investigations undertaken
Who has the authority to take action against an operator and nature of that authority
Current work being undertaken on the regulatory frameworks, quality assurance, etc.

The report on this stock-take is available from the Department of Labour, (Stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand: a contributing paper for the review of risk management and safety in the adventure and outdoor commercial sectors in New Zealand 2009/10, January 2010, ISBN 978-0-478-36033-2).

The review team also undertook a stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors internationally, including work underway to improve those provisions (e.g. international standards, regulations, licensing regimes). The report on this stock-take is available from the Department, (International stock-take of risk management and safety in the adventure and outdoor commercial sectors, January 2010, ISBN 978-0-478-36036-3).

Consultation

Questionnaires

In November 2009, the Department of Labour disseminated two types of questionnaire. It did this either directly to stakeholders or through peak industry bodies and government safety agencies and by making them available from its website. One questionnaire was for adventure and outdoor commercial sector operators, associations and organisations. The other questionnaire was for individuals such as academics and staff of adventure and outdoor commercial sector businesses.

Respondents were asked to tick one or more pre-determined boxes to describe their interest in the review and to answer set questions. The report on this consultation is available from the Department, (Summary of consultation responses: A contributing paper for the review of risk management and safety in the adventure and outdoor commercial sectors in New Zealand 2009/10, January 2010, ISBN 978-0-478-36039-4).

Submissions from the next-of- kin of people who died in the sector

The Department wrote to the next-of-kin of people who died while participating in the sectors during the five-year period from 1 July 2004 to 30 June 2009 informing them of the review and inviting them to submit comments.

Comments from people who responded are discussed in Appendix 5:.

Discussions with operators and other parties

Members of the working group conducted interviews with adventure tourism operators, local government representatives, a regional representative of the Department of Conservation, tourism marketing agencies and an academic working in the adventure tourism field. The aim of the interviews was to gather information to complete the gap analysis, especially in relation to activities about which the working group felt that it had less knowledge.

A total of 20 interviews were conducted in Queenstown and Rotorua involving 24 individuals. These regions were selected because they have a high number of adventure tourism operators.

Key issues the interviews focused on were:

The accuracy of information the Department held about specific activities
The working group's thinking about the coverage, quality and implementation of the variables being considered in the gap analysis
What new emerging activity providers did in relation to health and safety before commencing and during the first year or two of operations
Regulators' views on whether bylaws, licensing regimes or other schemes that were in place were adequate
What processes and practices land managers used to give consent for an activity on any land they managed and to monitor its ongoing operation
Whether regulators or land managers had any concerns about jurisdictional gaps
Criteria marketing agencies used for marketing operators
Auditing and quality assurance processes used by the sector
Qualifications
Where improvements might be made to risk management and safety.

The findings of the interviews are discussed in Appendix 5.

Comments from the external reference group

The 67-member external reference group for the review was consulted by email throughout the review. Comments received on the stock-takes, gap analysis and problem definition were considered and changes made to those documents as the working group found appropriate. Due to time constraints, some comments on the options and recommendations were able to be considered prior to completing this report, while others were not. Where comments from the group were not able to be fully considered prior to completing this report, arrangements were made to discuss these with the Minister of Labour.

National organisations focus group

The Department held a focus group with seven national organisations that have expertise in industry standards and guidelines, qualifications and knowledge of the New Zealand Outdoor Registration Board process to elicit their views on those matters. These organisations were the New Zealand Mountain Safety Council, Water Safety New Zealand, Outdoors New Zealand, New Zealand Outdoor Instructors Association, Skills Active, Adventure Tourism Travel Training Organisation (ATTTO) and Sport and Recreation New Zealand (SPARC).

The findings of the focus group are discussed in Appendix 5.

Gap analysis

The working group for the review undertook a high-level, five-variable gap analysis of risk management and safety provisions in the sectors to assist the governance and working groups in developing the problem definition and options and recommendations for the Minister.

The report aimed to identify where:

There are gaps in five key areas of risk management and safety provisions in the sectors (coverage)
These risk management and safety provisions could be improved (quality)
Operators need to improve their uptake of the risk management and safety provisions (implementation).

To enable it to complete the gap analysis, the working group first used a matrix tool to assess the activities examined by the review according to whether there is satisfactory coverage, quality and implementation of the following risk management and safety provisions that applied to them:

Activity-specific legislation or other controls for entry
Guidelines and standards
Qualifications and licences
Auditing and quality assurance processes
Relevant associations.

These five provisions were the variables about which information was obtained for the stock-take undertaken for the review. The working group considered that high coverage, high quality and high implementation of these variables were the appropriate benchmarks for the gap analysis (taking into account the fact that the HSE Act provides a generic rather than an activity-specific legislative framework for managing health and safety issues).

The working group made determinations about the level of coverage, quality and implementation of these variables drawing on: the New Zealand stock-take; responses to the consultation undertaken for the review; agency knowledge (including from other experts brought in to assist with the gap analysis); targeted field visits; and communications with other experts.

The working group then analysed the determinations in the matrix by activity and by variable.

Note that during this process the working group also developed a set of principles for operators which strongly guided its thinking. These are shown in Appendix 7.

Risk profiling

In order to make some determination about the scale of any risk management deficiencies affecting the sector, the working group undertook high level risk profiling for each activity covered by the review, assigning risk scores to each activity. The working group then compared the risk scores for each activity to the type of controls in place for those activities. The full methodology for this process and its findings are discussed under Appendix 6: Risk profiling.

Considering coroners' reports and judges' verdicts

A review of coroners' findings for 21 deaths in the adventure and outdoor commercial sectors during the five-year period covered by the review, and two relevant judges' verdicts, was undertaken to identify if the recommendations made might provide useful to inform the review. The findings are discussed in Appendix 5.

Problem definition

The review team then developed the problem definition. This has been amended for this report and has been re-presented as Section 4: Key findings.

Applying solutions to the different parts of the sector

When considering the options and recommendations for the review, the review team recognised that solutions will need to suit the different characteristics of commercial adventure tourism and outdoor education businesses. Differences and similarities between these types of businesses are shown below.

Adventure tourism context	Outdoor education context
• Commercial for profit businesses	• Mostly not for profit businesses
• International and domestic clients	• Primarily domestic clients • Clients tend to be school groups
• Tendency to shorter duration experiences e.g. < 1 day	• Often longer duration experiences e.g. 3-5 day camp
• Clients - tendency for individual rather than group bookings	• Clients tend to be group bookings rather than individual
• Seasonal	• Less likely to be seasonal
• Usually single activity experiences	• Often multi-activity experiences
• Primarily leisure objectives ("guiding")	• Often educational objectives (curriculum, instructional, nature, personal development)
• High levels of new clients (limited repeat visitation)	• Often repeat clients e.g. schools
• Less school-aged clients (predominantly 15-34 yrs)	• Clients are often minors
• Strong focus on marketing • Tourism distribution channel focus	• Limited marketing of activity
• Performance of sector has potential to impact NZ's international reputation	• Less likelihood of causing damage to international reputation
Similarities between Adventure Tourism and Outdoor Education
• Adventure tourism businesses are often contracted to run activities for outdoor education • Some businesses serve both markets • High cross-over of staff between sectors • Many independent contractors work both sectors • Successful new activities can grow quickly.

Note that the recommendations in this report apply to the commercial adventure tourism and outdoor education sectors and the sub-sectors within those that come within the terms of reference for the review.

Options and recommendations

After identifying the priority issues to be addressed (as shown in Section V of this report), the review team then developed options and recommendations. These are shown in Section VI: Initiatives to address the priority issues and Section II: Recommendations to the Minister of Labour of this report.

Appendix 3: The New Zealand legislative / regulatory context

This section has been reproduced from the report on the New Zealand stock-take done for the review.

Safety management framework applicable to the sector

No specific legislation covers the health and safety of participants in adventure tourism activities in New Zealand.

Instead, because the majority of activities are organised by businesses for gain or reward, the sector is regulated by means of the HSE Act, Maritime Transport Act and Civil Aviation Act. The HSE Act promotes the health and safety of people at work and those affected by workplace activities.

Where particular hazards or workplaces warrant it, or there is social consensus on how certain hazards should be dealt with, regulations may prescribe a particular means of addressing them. This applies to particular hazardous equipment, such as pressure equipment and other machinery, amusement devices, or workplaces such as mines, and the presence of young people in workplaces.

Overall it appears that the approach taken in the HSE Act is effective. Since the introduction of the performance-based regime, performance (in terms of improving safety standards) has generally improved. However, there is always scope for more acceptable solutions to be developed by different sectors (so that businesses know what they have to do to comply with the HSE Act requirements).

Numerous statutes have an impact on adventure activities. The publication New Zealand's Safety Related Law provides a comprehensive overview of the relevant New Zealand legislation and regulations related to safety or injury prevention. This can be found at: www.nzips.govt.nz/documents/safety_related_law_update_2008.pdf

New Zealand's no-fault Accident Compensation Scheme administers a 24-hour, 7-day per week, no-fault, comprehensive accident insurance scheme covering New Zealanders and those people visiting New Zealand. In return for this cover, people do not have the right to sue for damages if another person is at fault.

A significant network of sector-specific associations and user groups are an integral part of New Zealand's adventure and outdoor sectors. Associations (to a greater or lesser degree) organise meetings, workshops and newsletters for operators as well as provide a single point of contact for regulators or others who seek to work with the sector. A significant amount of activity is undertaken by these groups and a number have been involved in establishing industry codes of practice and standards for the adventure and outdoor commercial sector.

Agency jurisdictions and jurisdictional matters

The Department administers the provisions of the HSE Act and various regulations made under that Act (and both the CAA and Maritime NZ are designated agencies under Section 28B of the Act, that is, they are responsible for enforcing and investigating breaches of the Act in their spheres of jurisdiction).

The Department, CAA, Maritime NZ, DOC and territorial local authorities all have various jurisdictions for safety in adventure tourism.

Some agencies have the authority to certificate commencement of an activity for specified activities or to restrict its commencement through consenting processes, but licensing or approval is not required for many operators to commence commercial activity provision.

Powers to order adventure and outdoor commercial sector activities to cease to operate are similarly constrained.

Consumer education

A wide range of initiatives exist to educate consumers of adventure and outdoor commercial sector activities about the risks involved in participation and how to ameliorate those risks. These are carried out by a number of government and non-government agencies, and by the sector itself.

Agency resources

Agencies that are involved in the review report having varying levels of resources to carry out their regulatory functions in relation to the sector.

Commercial adventure aviation

'Adventure aviation' is the name given to a large and growing segment of New Zealand's adventure tourism industry. Adventure aviation operations are considered to be those operations carrying passengers for hire or reward where the object of the operation is for the passenger's recreational experience of participating in the flight, or engaging in the aerial activity.

By their nature and definition, adventure aviation activities involve a level of safety risk that is significantly higher than that encountered in commercial air transportation^[15]. Adventure aviation activities presently fall within a safety regulatory framework that was developed for purely sport and recreational purposes rather than commercial air operations. Comprehensive standards for entry control, monitoring, and exit control do not currently exist for commercial adventure aviation operations, and there is no existing CAA certification process for adventure aviation operators.

Accident and injury statistics covering adventure aviation activities are classified by the CAA under the "sport transport" safety target group. As of September 2009, the average social cost for adventure aviation activities was approximately $65.00 per person per hour of exposure. In comparison, the average social cost for air transport operations is approximately $0.10 per person per hour of exposure.^[16] In contrast to other safety target groups, the social costs associated with adventure aviation activities are significantly higher and trending upwards.^[17]

This review notes that the deficiencies in the safety regulatory framework applicable to commercial adventure aviation and the potential to improve the safety performance of the sector have already been identified by the Ministry of Transport. The nature of adventure aviation operations precludes them from the general concepts and safety standards for air transport operations that are required to be conducted under the Civil Aviation Rules applicable to 'normal' commercial air transport operations. The Ministry of Transport has a Rule (Part 115 - Adventure Aviation) at an advanced stage of development in the current aviation Rules programme approved by Cabinet which will prescribe requirements for the certification and continuing operation of operators conducting adventure aviation operations. Part 115 will apply to operators wishing to carry passengers for hire or reward while performing the following adventure aviation activities:

an A to A flight in an aeroplane or helicopter issued with a standard category airworthiness certificate conducting formation flight, aerobatic manoeuvres, and similar non-standard flight manoeuvres such as steep climbs, steep descents, and steep turns
an A to A flight (including an interim water landing for amphibious aircraft) in an aircraft issued with an appropriate special category airworthiness certificate
an A to A flight in a Class 2 microlight aircraft
a flight in a hot air balloon
a flight in a glider
a parachute-drop aircraft operation
a tandem parachute operation
a tandem hang glider (including para-glider) flight^[18].

The objective of Rule Part 115 is to:

improve passenger/participant safety
contribute to economic development by protecting and enhancing New Zealand's reputation as a safe place in which to participate in commercial adventure aviation activity
remove distortions from the current safety regulatory framework that unreasonably restrict certain activities from taking place and which see different safety standards being applied to very similar operations
provide a safety regulatory framework that encourages growth and innovation in the commercial adventure aviation sector.

Part 115 will require adventure aviation operators to be certificated in much the same way (although not to the same standards) as air transport operators that are currently required to be certificated under other Rule Parts. In particular, operators will need to satisfy the Director of Civil Aviation, through their exposition, that:

they have appropriate management systems, structures, and operating procedures in place to ensure compliance with the relevant safety standards
employees are appropriately qualified, and trained
equipment is appropriate to the task and properly maintained
key people are fit and proper to undertake their responsibilities.

In summary, the Ministry of Transport intends to:

define a new category of commercial aviation activity within the general aviation sector to be called "adventure aviation"
regulate the various activities that make up the commercial adventure aviation sector through a new rule Part 115 and through consequential amendments to existing rule Parts
develop within the proposed Part 115 a set of general requirements that are applicable to all adventure aviation operators along with separate requirements that are specific to the individual activities
include, as a key element of the proposed rule Part, a requirement for individual operators to hold an aviation document issued under Part 115
administer the proposed Part 115 utilising industry experience as much as is practicable.

Commercial jet boating and rafting

Commercial jet boating and rafting operations have been regulated since 1999 by Maritime Rule Part 80 made by the Minister of Transport in accordance with the process for rule-making in the Maritime Transport Act 1994. Part 80 sets specific minimum standards for the safe operation of commercial jet boats and rafts and no operations may commence until they have been inspected for compliance with those relevant standards. All jet boating and rafting operations are subject to ongoing and compulsory audit and inspection to ensure their continued compliance with Part 80.

The regulatory approach behind Part 80 has proven for the most part to be appropriate and serviceable, but a number of technical changes have been proposed following a review of the sectors by Maritime NZ. As a consequence, the Ministry of Transport proposes to replace Part 80 with two new rules - Maritime Rules Parts 81 and 82 - that deal separately with jet boating and rafting. Work on the amendments is well advanced.

Appendix 4: The international context

The stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors internationally undertaken for the review provided information about how New Zealand's safety management framework for the sectors compares to those of other countries. The international stock-take canvassed the regulation of adventure tourism activities in various countries, primarily in Australia, Canada, Chile, France, Ireland, Norway, Switzerland, the United Kingdom, and Utah in the United States. The summary of that report is reproduced below.

Size of the tourism sector

Tourism is a significant contributor to the economies of the countries examined: Organisation for Economic Cooperation and Development (OECD) data (2009) shows that as a proportion of GDP, tourism in general ranges from 2% in Canada to 6.3% in France (and 9.2% in New Zealand). The adventure activity sector is considered to be a growing part of the tourism industry in all of these countries. However, due to the lack of standardised definitions, it is not possible to provide a set of comparable statistics showing the size of the adventure activity sector in the countries examined in relation to employment numbers and types, participation, and economic value.

Incident rates

Information on incident rates in the adventure tourism sector internationally is poor. While work has been done on some activities and some locations, incident databases are in their infancy.

Approaches to safety and risk management

Internationally, risk and safety management in adventure activities has increasingly received the attention of government agencies. In addition to workplace health and safety legislation, regulatory or non-regulatory accreditation of safety provision in adventure activities (for people who are dependent on the leadership and judgement of others) can be categorised in the following ways:

accrediting the provider organisation's fitness to oversee the risk management and safe delivery of the activity
certifying the activity instructor/guide who is with a dependent client.

Accreditation (not statutory regulation) of providers is overtaking the certifying of instructors/guides. Provider accreditation takes into account all the elements of operational quality (one of which is instructor/guide qualifications and competence).

In the countries examined in this work, provider accreditation is generally non-statutory and incorporates inspection. An exception to this is for providers of some activities for under 18-year-olds not in the company of their parents in the UK.

Although this review has found little comment on the relative merits of statutory versus non-statutory schemes, the latter appear to be preferred perhaps because:

voluntary regimes may in effect be obligatory in order for providers to obtain insurance, access public land or make use of state supported marketing
statutory regulations tend to set minimum standards whereas accreditation emphasises high standards
non-statutory accreditation schemes provide a balance between credible assurance of safety standards without excessive administration burdens on providers or supervisory bodies.

The table below indicates the approaches taken to the adventure tourism sector as a whole by the jurisdictions included in this review.

Non-statutory accreditation programmes	Statutory regulations	Other
Australia - Adventure Activity Standards	Costa Rica - Regulations for the Operation of Adventure Tourism Activities	Northern Ireland - currently considering an accreditation scheme
Brazil - Aventura Segura programme	France - statutory qualifications for activity leaders
Chile - Quality System for Adventure Tourism	United Kingdom - AALA^[19] (under 18s without parental guidance)
France - Quality Tourism brand	Yukon (Canada) - Wilderness Tourism Licensing Act
India - Basic Minimum Standards for Adventure Tourism activities
New Zealand - Outdoorsmark^[20]
Switzerland - Safety in Adventure certifications
United Kingdom - Adventuremark

Effectiveness of approaches

No material evaluating the various approaches in relation to improved safety was found in the course of this work, however licensing or accreditation of the provider rather than certification of an instructor or leader appears to be preferred presumably because it encompasses more dimensions of performance than instructor accreditation.

Annett (2005) who reviewed the approaches in a number of countries considers (without providing supporting reasons) that the most effective schemes are those in France and the UK where it is an offence to offer some activities without going through the appropriate systems and where there are statutory standards and safeguards in place to protect the dependent participant's interests.

Current work on approaches to safety and risk management

The International Organisation for Standardisation (ISO)^[21] is currently working to develop consensus-based international standards in adventure tourism that would provide a common basis for safety management. At the time of writing, New Zealand is not participating in this. The new Working Group on Adventure Tourism leading this work will focus on developing working plans that lead to three new areas of international standards including:

Safety management requirements (including a glossary of terms)
Leader/guide competence/cies
Minimum information provided to clients^[22].

The timeframe for completing these standards was not known to the Department at the time of writing this report. The Department recommends investigating whether New Zealand should be represented on the working group.

Appendix 5: Review findings

A. The New Zealand stock-take

The New Zealand stock-take undertaken for the review should be read in conjunction with this report. The stock-take is available from the Department, (Stock-take of risk management and safety provisions in the adventure and outdoor commercial sectors in New Zealand: a contributing paper for the review of risk management and safety in the adventure and outdoor commercial sectors in New Zealand 2009/10, January 2010, ISBN 978-0-478-36033-2).

B. The gap analysis

The gap analysis undertaken for the review involved an analysis of the activities according to whether there is satisfactory coverage, quality and implementation of:

Activity-specific legislation or other controls for entry
Guidelines and standards
Qualifications and licences
Auditing and quality assurance processes
Relevant associations.

Coverage in this context refers to whether activity-specific legislation or other controls for entry, guidelines and standards, qualifications and licences, safety auditing processes, and relevant associations exist, are in place or are available.

Quality in this context refers to whether activity-specific legislation or other controls for entry, guidelines and standards, qualifications and licences, safety auditing processes, and relevant associations are fit for purpose and of a high standard.

Implementation in this context refers to whether activity-specific legislation or other controls for entry, guidelines and standards, qualifications and licences, safety auditing processes, and relevant associations are fully implemented, and/or have buy-in or uptake.

The findings of the gap analysis in relation to the five variables were as follows.

Activity-specific legislation or other controls for entry

Based on the information available to it, the working group noted that activity-specific legislation and/or activity-specific controls for entry apply to the following activities examined by the review:

Cycling (the Road Code for Cyclists)
Hunting (Firearms Regulations 1974)
Infrastructural attractions, including go karts (Amusement Device Regulations 1978 and Code of Practice for Passenger Ropeways in New Zealand AS/NZS 5848)
Motorcycle touring (Land Transport Rule: Operators Licensing 2007)
Aspects of ski-field operations (HSE Pressure Equipment, Cranes and Passenger Ropeways Regulations 1999 apply and other legislation for the road access ways where they are private roads)
Diving (numerous - see New Zealand stock-take for the review)
Jet boating (Maritime Rule Part 82 - Commercial Jet Boat Operations and Part 80 Marine Craft used in Adventure Tourism)
Rafting (Maritime Rule Part 80 Marine Craft used in Adventure Tourism/81 Commercial Rafting Operations)
All aviation activities (Civil Aviation Act 1990).

For other activities, no activity-specific legislation applies in relation to the health and safety of participants. Instead, because the majority of activities are offered by businesses for gain or reward, the sector is regulated by the HSE Act.

Additionally, DOC concessions are required for all commercial activities on public conservation land and QLDC's district plan requires that any operator of any adventure tourism activity seeks resource consent once that operator has provided the activity to five people for reward (it is then defined as 'commercial'). It is a requirement for a concession from DOC and for resource consent from QLDC that applicants have a safety management plan.

When considering the quality of the activity-specific legislation or other controls for entry that apply to the activities examined by the review, the working group was interested in their fit for purpose. It noted the following issues with the activity-specific legislation that is in place for some activities.

The Amusement Device Regulations 1978 need reviewing. A review of these regulations is planned for 2010/11
Amendments are being proposed to the existing rules for jet boating and rafting
The proposed CAA Part 115 Rule will address concerns about the legislation covering adventure aviation activities.

In terms of implementation of legislation or other controls for entry, while not activity-specific, the working group heard that some operators are likely to be transporting passengers without a current passenger endorsement on their drivers licence. Whether using a bus, shuttle, taxi or another vehicle, if operators carry passengers for some type of fee, their drivers' licences must include a current passenger (P) endorsement. This verifies that they have the proven skills to provide this service safely.

Guidelines and standards

Based on the information available to it, the working group noted that guidelines and standards of some form exist for most activities, but were notably absent for:

Hot air ballooning
Infrastructural attractions (e.g. bridge swinging and flying fox-type thrill rides)
Luge riding^[23] / go karting
Marine mammal swimming
Motorcycle touring
Sand boarding
Surfing
Water skiing.

When considering the quality of the guidelines and standards that apply to the activities examined by the review, the working group made some key assumptions. These were:

New Zealand Standards that apply will be of a high standard
The proposed CAA Part 115 Rule will introduce standards that are fit for purpose
The code of operation for riding plastic spheres (globe riding) is likely to be of a high standard as the operator has involvement in international forums for safety management, has worked to meet the ASTM (American Society for Testing and Materials) F119 standard on emerging attractions, and has attained insurance through an international firm for that activity.

The working group was not able to assess the quality of the guidelines and standards that are available for the activities examined by the review, but noted the following gaps in development or implementation.

The draft code of practice for heli-ski operators needs further work before it can be considered functional
The review of guidelines for river boarding/river sledging is not yet complete
There appears to be variable buy-in and uptake of the guidelines and standards for indoor rock climbing, mountain biking and quad bike touring
There appears to be poor uptake of available guidelines for land-based fishing
Guidelines and standards for commercial microlight activities are not implemented although these standards will be included in the proposed CAA Part 115 which is strongly supported by the microlight sector.

Qualifications and licences

Based on the information available to it, the working group noted that qualifications of some form exist for most activities, but appeared to be notably absent for:

Canyoning (although a range of relevant qualifications in related activities - e.g. caving - do exist)
Cycling (although Cycle Tour Operators of New Zealand have internal competencies - Guide Mechanic Standards (Cycle 1 and Cycle 2))
Quad bike touring
Motorcycle touring
Globe riding (plastic spheres).

The working group also noted that the development of specific white-water boarding qualifications remains in progress.

When considering the quality of the qualifications and licences that apply to the activities examined by the review, the working group made a key assumption that qualifications registered on the New Zealand Qualifications Framework are fit for purpose (note that to appear on New Zealand's Register of Quality Assured Qualifications, qualifications must be approved and quality assured, and delivered by an accredited education or training organisation).

The working group was not able to assess the quality of the qualifications and licences that are available for the activities examined by the review, but noted that clarity is needed in terms of which qualifications relevant to kayaking apply in different environments (e.g. sea kayaking versus swift water kayaking).

The working group noted the following concerns about implementation of the qualifications and licences that are in place for some activities:

Hunting and mountain biking operators show poor uptake of the qualifications available for these activities
Several operators reported that Transport Service Licence endorsements on drivers' licences took too long and were too expensive to obtain. This led some operators to avoid obtaining them (and not pursuing obtaining a Qualmark audit because of this). Several operators reported difficulty complying with the requirement for a Transport Service Licence because of a shortage of people who held them to employ.

Safety auditing processes

Based on the information available to it, the working group noted that Qualmark, ROSA or OutdoorsMark safety auditing is available for all activities, should they wish to be audited. Additionally, safety auditing processes are available for all water-based activities required to meet vessel and equipment audits under maritime rules. Safety audits under the ACC's Workplace Safety Management Practices Scheme are also available for some activities and Bureau Veritas is also available to audit some operations.

In the time available, the working group was not able to assess the quality of the safety auditing processes available for the activities examined by the review. However, it noted the following points in relation to the safety auditing processes that are available:

Some Qualmark Tertiary criteria are in need of review and this process has begun
The coroner's findings^[24] in respect of the 2008 Mangatepopo Gorge canyoning tragedy included a recommendation that Outdoors New Zealand reviews its policies and procedures around the OutdoorsMark safety audits and the training provided to its auditors. Note that the working group understands that Outdoors New Zealand undertook an internal review of all processes associated with OutdoorsMark after this event, annual moderation processes continue to be reviewed, and an external review of OutdoorsMark is underway.

The working group noted that the following activities appeared to have poor or variable uptake of safety auditing processes.

Events (unless they were international events)
Quad bike touring
Land-based fishing
Indoor rock climbing
Motorcycle touring
Diving (from vessels greater than six metres operating beyond five nautical miles from shore)
Surfing
Water skiing
Hot air balloons.

Relevant associations

Based on the information available to it, the working group noted that relevant associations do not appear to exist for the following activities.

Canyoning (although one is being formed)
Quad bike touring (although a strong user group exists)
Horse trekking
Indoor rock climbing
Infrastructural attractions
Luge riding/go karting
Motorcycle touring
Sand boarding (although there appear to be few operators in New Zealand)
Globe riding (there is only one operator in New Zealand)
Marine mammal swimming
Water skiing
Microlight passenger flights.

The working group was not able to assess the fit for purpose of all of the associations available for the activities examined by the review, but made the following observation:

Cycle Tour Operators of New Zealand is working to make its organisation more relevant to mountain biking operators to attract more members and to be more representative of the wider cycle tour industry.

The working group noted that the following activities appeared to have poor or variable uptake of membership in associations, where associations exist.

Cycling (amongst smaller operators)
Small events
Heli-skiing (the operators' group being quite new)
Walking/tramping
Sea kayaking
Diving.

C. The consultation

The summary report on consultation responses developed for the review should be read in conjunction with this report. The report is available from the Department, (Summary of consultation responses: A contributing paper for the review of risk management and safety in the adventure and outdoor commercial sectors in New Zealand 2009/10, January 2010, ISBN 978-0-478-36039-4).

D. What families told us

People who lost a family member to a fatal incident while they were participating in adventure or outdoor commercial sector activities in New Zealand during the five-year period covered by the review were invited to submit comments. Responses were received from six families. The review team acknowledges that it would have been difficult for families to engage in this process.

Families made a number of recommendations to improve the risk management practices of adventure and outdoor commercial sector operators.

The overwhelming message communicated by families was the need for change. A key change recommended was in safety culture. One of the families noted the following Taiwanese proverb to illustrate this point:

'The attitude determines the altitude' - this is to say that from a person's everyday manner, one can tell his/her judgement and attention to detail.

Families sought an assurance that there will be more accountability for actions and decisions from regulatory agencies and adventure tourism operators.

Themes in families' responses

Themes in the responses from families have been summarised below.

Effect on families

Families expressed that the pain, impact and sense of suffering that they endure due to the loss of a loved one is immense and immeasurable. There is nothing that can replace their grief and loss. This loss extends to the loss of enjoying a future life together and the ongoing impact of the death. They said there would, however, be some assurance and comfort in knowing that the legacy of the death of their loved ones was that improvements in safety were made.

Two families said that the differences between Eastern and Western cultures need to be considered. This includes acknowledging the pain and difficulty associated with spiritual damage that has a negative impact on family members' health and quality of life and the impact of the long-term financial loss through losing a main income earner for the family.

This was articulated in one of the responses:

In Chinese society, the child is responsible for supporting his/her parents. This is the standard rule of filial piety. To be more specific, in a Chinese family, the child is part of the property of the parents, and is their retirement fund. Therefore, we lost our only child, lost the extension of our generation and the chance of enjoying life together with our offspring, and also lost our only hope, property and future.

Two families expressed a high degree of dissatisfaction with the action taken by the regulatory authorities against the operators offering the activities in which their loved ones died. They said that this compounded their grief.

Families' recommendations were:

There should be more attention to the difficulties and cultural differences experienced by the parents of international students as the result of an accident
The New Zealand government should provide interpreting assistance for families where required
The New Zealand government should provide support for families to enter New Zealand, and all other necessary and relevant support
The New Zealand government should issue a special permit that would give the deceased's family a status equivalent to New Zealand residents that would allow relatives to visit the accident site from time to time. In addition, a special permit would allow families to live in New Zealand long-term to benefit from the mutual support of other families who suffered as a result of the same accident.

Safety Culture

Families said that there could be improvements to the safety culture of some companies and staff attitudes. Recommendations were:

The attitude of staff should be more careful, and the level of professional qualifications and observation ability must be improved
Companies should clearly communicate the risks involved with an activity to clients in advance of undertaking the activity
Safety and risk management should be the top priority for all outdoor events. Event managers, marshals and participants should be more aware of their responsibilities and the risks involved and follow good practice. They should listen and act on any information received.

Efficiency of the New Zealand justice system

Some families said that they felt that the efficiency of the New Zealand justice system was low. They said that the length of time it took to prosecute and sentence operators added to their distress. They also noted that financial compensation payments were not always made in a reasonable time. Their recommendations were:

Improvements need to be made to New Zealand's justice system that reduce the length of time between prosecution and sentencing
Regulations should be put in place that allow for the prosecution of individuals who cause death or injury.

Coronial System

Families said that they considered the length of time it could take for a coronial inquest to occur was an unacceptable system failure that also led to delays in any recommendations being implemented. A recommendation was:

Improvements need to be made to the Coronial system to reduce the length of time between a death and an inquest occurring.

Compensation is low and inadequate to cover costs

Where ACC payments or payments by operators have occurred, the financial compensation is considered to have been minimal. Families reported that often, the compensation payments have not covered the costs of visiting New Zealand to make arrangements following the death. One family noted that New Zealand compensation levels are below those of some developing countries. This is seen as demonstrating that the New Zealand government does not value safety and take risk management seriously. A recommendation was:

There should be higher financial compensation for families following an accident.

New Zealand's no-fault accident compensation scheme

Some families considered that New Zealand's no-fault accident compensation scheme and 'no compulsory security provisions' were inappropriate for a developed country. Some also said that the inability to sue operators in New Zealand, except for exemplary damages, provided no incentive for companies to have good safety practices. A recommendation was:

There should be compulsory business insurance and 'security provisions'.

Inadequate penalties for non-compliance with legislation

Some families said that minimal fines and low levels of enforcement were a disincentive for compliance with safety legislation. They said that the minimal fines did not deter companies from taking high risks and ignoring guidelines.

One family noted that the fine for a company that was prosecuted for a fatality was inadequate and would not have equalled the amount of money that was spent by the person who died while they were in New Zealand as a tourist before their death. A recommendation was:

There should be higher penalties for operators who are prosecuted and found guilty.

Licensing

Some families considered that licensing adventure and outdoor commercial sector businesses was necessary. They said this would:

Ensure that businesses do not commence operating without any controls
Ensure new activities meet safety standards and have safe operating procedures before they start operating
Change the safety culture of individuals within some companies.

A recommendation was:

There should be licensing of adventure tourism business operators to ensure businesses do not commence operation without any controls and that new activities meet safety standards and have safe operating procedures before they start operating.

Limitations of the HSE Act

The HSE Act was considered by some families to have a number of limitations and "lack teeth" as a mechanism for managing adventure tourism activities. Specific concerns were:

The HSE Act is being administered in a reactive rather than proactive way
The HSE Act is not enforced by regular visits to companies or by any other means
Lack of proactive enforcement contributes to companies taking risks
By default, a new activity can commence without inspection.

Families' recommendations were:

The Department of Labour's investigation and prosecution procedures should be more robust
There should be a requirement for external checks
New Zealand government authorities should inspect and examine the equipment of outdoor activity companies and the safety of the activity from time to time.

Adequacy of guidelines

Families said that existing safety guidelines for operators need to be improved. This included specifying safe operating procedures and equipment requirements specific to activities. Recommendations were:

There needs to be a higher degree of clarity about the safety obligations of operators, and existing guidelines need to be improved. This includes specifying safe operating procedures and equipment requirements specific to activities
Adventure activity standards should be implemented that are similar to those in Australia. Standards should outline risk management and key business practices, such as emergency procedures and leader competency, with the aim to encourage responsible and consistent practices across New Zealand's adventure industry.

Equipment

Families said that operators should have adequate and fit for purpose equipment for the activity. Their recommendations were:

To review the rescue method and rescue equipment held by each outdoor activity company
People participating in rescues should be provided with better and more advanced equipment
The leader of each activity team should be equipped with better and more advanced tools for rescue
There should be roll bars on quad bikes
Personal Flotation Devices should meet safety standards.

Media coverage, advertising and information on company websites

Some families commented on partial reporting by media and the impact this had on them.

One family expressed concern that a company involved in a fatal accident stated on its website that it had won an award. The marketing was viewed as very painful for the next of kin.

Families' recommendations were:

The government should restrict the media to impartial reporting which does not blame the victims and avoids causing additional hurt to the victims' families
Advertising information and endorsements by tourists on company websites where those companies have had a fatal accident should be banned.

Recommendations made by families whose loved ones died in the Mangatepopo Gorge tragedy (specific to outdoor education activity)

Relevant authorities and agencies (such as the Ministry of Education, agencies organising outdoor activities, evaluation agencies, training companies and schools) should ensure that school teachers and outdoor activity instructors understand the meaning of "catchment area" and "run off detention effect"
Schools should be one of the supervision authorities in addition to the provider that organises the activity. Even if a school has signed an agreement with the activity supervisor, they should have responsibility as a supervisor
Staff from relevant agencies should never allow students to undertake water-based activities when the water has been estimated to be low by eyesight only
Each leader's experience, professional knowledge, observation ability, sense of judgement, emergency management skills and skills in leading students out of emergency situations must be strengthened
Individuals whose work involves keeping people safe should have to pass some kind of national qualification and be licensed.

Activity oversight by voluntary associations

While it was acknowledged that activity-specific voluntary associations can provide a forum for sharing information and providing training courses, they were not considered effective as a means of setting consistent standards for all businesses. Voluntary associations were seen as more effective for the companies that are already well managed and take safety seriously.

Difference in criteria for running activities

Families said that there should be consistency in controls and requirements to operate an activity.

E. Lessons learnt from fatalities

Review of coroners' reports and judges' verdicts

A review of coroners' findings for 21 deaths and two judges' verdicts was undertaken to identify if the recommendations that were made might provide useful information to inform the review.

The Coronial Service of New Zealand provides an independent coronial system for investigation and to prevent deaths and promote justice through:

Investigations, and the identification of the causes and circumstances, of sudden and unexplained deaths, or deaths in special circumstances; and
The making of specified recommendations or comments that, if drawn to public attention, may reduce the chances of the occurrence of other deaths in similar circumstances.^[25]

As a number of case files are still active and under the jurisdiction of a coroner, not all relevant case information could be reviewed. Additionally, three coroners' reports made no recommendations or comments.

The deaths covered by the coroners' reports occurred in the following activities: heli-skiing, mountain climbing, skiing, quad bike touring, infrastructural attractions, diving, canyoning/outdoor education, indoor rock climbing and events - motorbike racing. The two judges' findings related to quad bike touring and river boarding.

There is an emphasis in the coroners' findings and judges' verdicts on the importance of operators not only having safety management procedures in place to manage the risk of the activity, but also having some assurance that the procedures are being implemented. One of the features of participating in a high risk activity is that often it is carried out in extreme and not always predictable terrain, and as such there is an inherent risk to those participating in the activity that cannot be entirely eliminated.

In the inquiry into the deaths that occurred at the Sir Edmund Hilary Outdoor Pursuits Centre, Coroner Devonport summarised the importance of having proper risk identification and risk management procedures in place in his final comment:

All reasonable steps must be taken to minimise the chances of serious injury. Proper risk identification and risk management is vital to avoid serious injury or death. In the Mangatepopo gorge, this requires an awareness of the environment, identification of hazards, proper assessment of the likelihood of adverse events occurring, and plans prepared if an adverse event occurs. Even if those risk management strategies are in place, complacency can defeat them. Continual awareness is required. For commercial/educational outdoor educational institutions, regular emergency exercises are required.

Under the HSE Act, adventure tourism operators have a duty of care to their participants and are therefore liable should they fail to provide the appropriate standard of care to their participants.

As Judge Tompkins put it in his decision in the case of the Department of Labour versus Waitomo Big Red Limited^[26]:

Generally, the scheme of the Act is preventative, in that it places relatively onerous positive duties on, in this case, the defendant company, to seek out relevant hazards, then proactively anticipate the possible harm, and to 'take all practicable steps' to ensure that no hazard is present or arises that cases harm.

Judge Tompkins also states:

There is, by the Act's adoption of the necessarily relative concepts of 'reasonably practicable...in the circumstances', a balance to be found. It is neither possible nor desirable to remove all risk. To do so would be to the longer term detriment of New Zealand.

The coroners' recommendations and judges' verdicts provide guidance on the expectations of how adventure tourism operators should meet their legal obligations to operate within reasonable levels of risk to protect client safety.

Key recommendations in coroners' reports

Coroners made the following recommendations:

Emergency procedures

Ensure that, at all times in which it is technically and practically possible, a client has an independent means of summonsing help in the event of incapacity of their guide
All individual companies should have emergency procedures and systems in place, and where practicable, these are tested.

Auditing

Ensure that facilities are formally inspected at regular intervals
Outdoors New Zealand should review its policies and procedures around the OutdoorsMark safety audits and the training provided to its auditors.

External safety training and education

Operators should seek external safety training and education.

Guidance from national organisations

Operators should take guidance from national industry organisations
National organisations and/or associations should establish an annual "skills and knowledge" meeting to be run in conjunction with the annual general meeting, to include discussion and analysis of any incidents/accidents of the past year and of previous years, if relevant, and to promote knowledge to their members of the content and findings of the session.

Equipment

Ensure regular maintenance of equipment or facilities.

Information so clients can make informed decisions

Provide information for clients to make informed decisions about their skill levels and ability to participate in the activity
An information sheet should also give basic instructions on safety, including emergency contact details if something goes wrong
Clients should understand the risks of participating in the activity and have the informed opportunity to continue with the activity or not.

Licensing of outdoor education/adventure operations

Government should consider licensing outdoor education/adventure operations which provide activities to persons under 18 years of age to ensure minimum standards are met.

Meteorological Service (MetService) weather warnings and forecasts

The MetService should include severe weather warnings in applicable regional forecasts
The MetService should issue written forecasts with the time of the preparation of the forecast clearly displayed
The MetService should review its procedures around follow-up communications to forecast recipients when there is an error in a forecast.

Infrastructural Attractions (Amusement Devices)

The Department should prepare clear operational guidelines and training procedures for operators of amusement devices that cover all aspects of safe operation of such devices.

Canyoning

Advice should be given to the public and in particular, training institutions, including polytechnics, that linking individuals swimming or floating in moving water is potentially dangerous.

White river boarding

Operators should seek out external white water safety training and education.

F. Lessons learnt from workplace serious harm accidents

Due to the limited centrally-held data held by the Department of Labour on the cause and outcomes of serious harm accidents, the working group was not able to conduct a review of serious harm accidents to determine lessons that might be learnt. Readers of this report should also note the following key issues with the recording and reporting of statistics given for workplace serious harm accidents and fatalities.

Serious harm accidents

The working group acknowledges that there is likely to be under-reporting of workplace serious harm accidents
Some workplace serious harm accidents have been reported and recorded as such when they appear not to have been workplace serious harm accidents according to the definition of serious harm. Data available at the time of writing this report did not allow the working group to isolate out those cases
Some workplace serious harm accidents may not be fairly attributable to the provision of the activity (e.g. one 'accident' reported was a member of the public suffering a seizure while entering the jump area for a bungy)
Some workplace serious harm accidents may not be fairly attributable to the activity provider (e.g. a mountain boarder who injured his wrists was not wearing wrist guards despite them being supplied and a recommendation made that they be worn)
Classification of workplace serious harm accidents by activity type is inconsistent in some cases (e.g. dirt bikes classified as motorcycles in some cases and mountain bikes in others)
ACC claims from employees of adventure and outdoor commercial sector operators who are injured while providing the activity to clients are registered as workplace accidents, but ACC claims from clients participating in the activities are registered as recreational activities.

Fatalities

Some fatalities may not be fairly attributable to the provision of the activity (e.g. death of a fishing guide and his client in a hut)
Where a fatality is deemed not to have occurred in a workplace, it is referred to the appropriate agency (e.g. Energy Safety Services or the New Zealand Police)
Some fatalities may not be fairly attributable to the activity provider (e.g. a possible cardiac arrest while diving).

G. Interviews with operators and other agencies

Members of the working group conducted interviews with adventure tourism operators, local government representatives, tourism marketing agencies and an academic working in the adventure tourism field.

Key themes from the interviews

Changing safety culture

Some operators said that the main challenge they face is changing the safety culture of a few, and sometimes new, businesses who operate less professionally and 'under the radar'. They said that the current operating environment has allowed some businesses to commence and operate for a length of time (sometimes years) without any entry requirements, standard operating procedures in place, health and safety policies for staff or external audits and reviews of safety.

One suggestion to reach those 'under the radar' was providing mentoring and assistance for new operators. This could include 'assistance packages' or 'templates' on what constitutes good safety and business practice, and support on issues such as where to obtain advice on specific health and safety information, how to manage staff and managing internal and external communications.

One larger operator worked to improve safety culture by linking internal safety audits to remuneration.

Information sharing

Some companies and operators told the working group members that they exchange information with other operators, including incident data, and actively engage in peer review of practice. However, it was also identified that commercial considerations were sometimes a barrier to sharing information. Another barrier identified was that some operators were reluctant to share information with regulatory authorities in case of possible "blame culture" ramifications or possible prosecution.

Voluntary auditing schemes

There was very strong feedback from the discussions that for external auditing of operations to have credibility with operators/owners, it needed to be undertaken by peers, or where there were a limited number of people with the specific activity expertise, by people/organisations who had outdoor experience and an understanding of the wider sector issues. They said that external auditing needed to have some "added value" component for owners/operators. They said that this could include advice on ways to improve safety and business practice and external auditors could also assist operators to develop risk management plans.

Qualmark

Several interviewees commented on Qualmark auditing and queried whether Qualmark was sufficiently fit for purpose for assessing the safety of adventure activities. They said that while the Qualmark assessment included aspects of commercial business operations that can influence and drive good safety management, often the audits were perceived as service-driven,and not providing depth in terms of assessing risk management or safety practice.

ACC Workplace Safety Management Practices programme

Larger operators indicated that the ACC Workplace Safety Management Practices (WSMP) programme provided a robust auditing process. They said that the reward-based nature of the system worked well for larger operators who employ a number of staff.

One operator suggested that there would be some value if aspects of Qualmark and WSMP could be combined, or if there was some mechanism where Qualmark, ROSA or OutdoorsMark could be 'bolted on' to the WSMP programme.

Qualifications

Some operators said that qualifications were not always viewed as a measure of competence. They said that they were recognised as a way for individuals to acquire knowledge in a limited time, but not as providing the exposure to experience that allowed individuals to have the knowledge to run an operation safely. They said that relevant outdoor experience was often the determining factor for them when employing staff.

Other operators stated that they prefer a mix of qualifications, experience and 'nous' and encouraged uptake of qualifications based on need. Time-in-field training was valued equally, if not more, by some operators as a way to improve skill sets and competence.

Suggestions for improvements to qualifications

Some operators said that the current qualifications funding model was inadequate to cater for specialist training requirements where they are needed by only a few staff of some activities. They said this could be improved by having a clear qualifications pathway that provided incentives for individuals to up-skill or obtain a qualification.

Some operators commented on the difficulties for staff to obtain a Transport Service Licence endorsement on their driver's licence. They said it can take up to eight months to obtain a licence due to Police and immigration requirements. They said that as there was a shortage of staff with licences, this could have a significant impact on smaller operations.

Some operators suggested the quality and availability of the Pre-hospital emergency care qualification could be improved. They said there was a minimum requirement of 10 people for a tailored course to run and that this restricted when courses were available and when staff could attend. This qualification was considered a minimum requirement for staff to be competent in emergency procedures.

Professional associations

Professional associations were considered important for supporting operators to deliver safe and professional services. However, some professional activity-based associations were not considered effective in providing a forum for sharing health and safety information. A strength of professional associations was considered to be their ability to set a national guiding standard specific to the activity they were involved in.

User groups

In addition to professional associations, a number of operators said they belonged to industry user groups. They said that a strength of user groups is that their voluntary nature allows people/companies to achieve changes that would be difficult or take time through a regulatory process. Difficulties identified with user groups included that some were more active in regions than others, and that the funding and time commitment required to keep the user groups active was significant.

Marketing of adventure tourism activities

The two marketing agencies interviewed viewed their roles as destination marketers. They said that they had no safety criteria for agreeing to market operators.

Local government

The Local Government Act provides for communities to determine their own priorities and their own approaches to service provision. Regional councils operate in and on the same land that sits within territorial authorities (district and city councils), and some districts have multiple regional councils (e.g. Taupo District is covered by four regional councils). This creates substantial boundary and jurisdictional issues to be managed.

In consequence, local government approaches to public safety and the levels of intervention (especially on private land) vary widely among different authorities. At one end of the spectrum are the many councils that view safety in adventure tourism as a Department of Labour concern for efficiency and capability reasons. In their view:

It is more efficient to have a single regulator than to have many all addressing the same issues. For example, across-boundary jurisdictional issues would impose varying requirements for safety management systems. If operators worked across local authority boundaries, they may need approval from multiple agencies
Most local authorities are too small to retain complex safety regulation capability and expertise within their districts.

QLDC operates at the other end of the spectrum, requiring operations that have guided five people as a commercial activity to apply for resource consent. QLDC undertakes an initial assessment of the health and safety provisions of new activities and seeks external expert advice when it does not have sufficient knowledge internally to assess these provisions. For water-based activities, it seeks advice from the harbourmaster.

One large Queenstown operator commented that the resource consent process could be a time-consuming, slow and expensive process, especially if it involved the Environment Court.

Comments made by operators on DOC functions

Most safety plans that are developed to meet DOC concession requirements are audited and approved for up to five years. However, if significant infrastructure is included the approval can be for much longer.

Three operators noted that the requirement to obtain a safety audit to obtain a DOC concession had assisted with developing their company's individual safety plans.

It was noted, however, that DOC did not check compliance once an operator had a safety audit. Operators also said they were aware of overseas guides operating illegally without DOC concessions or external checks.

Staff

Some operators said that the seasonal nature of some activities had an impact on their ability to retain staff.

They commented that it was often easier to recruit temporary overseas staff who had the relevant qualifications and experience to meet seasonal requirements.

Of concern to the working group was that some operators indicated that they did not have written standard operating procedures or policies for staff, although they may have a detailed company health and safety plan.

Department of Labour registration process for certification of amusement devices

Two large operators noted that they had difficulties with obtaining their Amusement Device Regulations registration. One said that their first Department inspection occurred six months after their businesses had been operating. While they considered that the Department provided useful business operational recommendations, they said they would have found it more useful to have the Department's input and oversight at an earlier stage. One said that a difficulty with obtaining registration was that the Department did not recognise a local engineer as suitable for the third party engineering check of machinery required, even though the engineer was recognised internationally.

Department of Labour Codes of Practice

Some operators commented that they have found the development of the Department's codes of practice useful for providing safety guidance (e.g for indoor rock walls).

H. Advice about qualifications, standards, guidelines, training and experience

The Department received advice from peak bodies involved in qualifications and safety in the sector, and also operators, about the importance of qualifications, standards, guidelines, training and experience. It also held a focus group with seven national organisations with expertise in industry standards and guidelines, qualifications and knowledge of the New Zealand Outdoor Registration Board (NZORB) process which provided further advice. These organisations were:

New Zealand Mountain Safety Council
Water Safety New Zealand
Outdoors New Zealand
New Zealand Outdoor Instructors Association (NZOIA)
Skills Active
Aviation Tourism Travel Training Organisation
Sport and Recreation New Zealand.

NZORB is a joint initiative between the New Zealand Mountain Safety Council, Skills Active and NZOIA. The Board provides a revalidation scheme for existing qualifications for individuals. Revalidation can be signed-off by an approved organisation where internal training is strong or if an organisation has OutdoorsMark.

One large organisation involved in providing qualifications for the sector pointed out the importance of the following:

Having a qualified and registered workforce (reflecting revalidated qualifications also)
Supporting providers of qualifications within outdoor recreation
Supporting qualifications themselves
Supporting NZORB.

It was felt that it was crucial that the review team firmly supported good employers who encouraged and supported their staff through qualifications, as well as the many people who voluntarily and at considerable expense gained qualifications, and who revalidated their qualifications to ensure they were up to date and working to recognised standards of best practice by attending refresher training and registering with NZORB. These views were similarly expressed in the national organisations focus group.

Two key reasons why qualifications were so important in the sectors were pointed out by the training provider. These were as follows.

1. Ongoing personal recreational involvement

Since many people receive their first experience of outdoor recreational pursuits on commercially provided activities, it is essential that they observe best practice being role modelled and are provided with the correct safety messages and skills on a consistent basis. Failure to deliver this level of quality may create problems for the future particularly if the participants go on to take up these activities for their personal recreation. The provision of a safe experience is one thing; the provision of a quality experience is another. Quality is critically important for safety. Focusing solely on serious harm accidents and fatalities within workplaces is overly simplistic and overlooks the impact that poor role modelling and instruction may have during later independent activity.

The ACC Drowning Prevention Strategy and River Safety Education Strategy are examples of current initiatives that recognise this issue and seek to act in a preventative way by ensuring that participants receive quality instruction and leadership which conveys clear and consistent safety messages.

There are significant indirect consequences of poor leadership and supervision.

2. The employee

A focus on safety assurance at an organisational level is not enough. A recommendation or strategy is needed for upgrading the overall skill level of the labour force and recognising the particular and significant role played by the employee in the uncontrolled outdoor environment. By international standards New Zealand does not have a highly skilled work force in large parts of the adventure activity industry (although there are notable exceptions). Indeed significant numbers of people enter the industry unqualified and leave before ever gaining a qualification. By contrast, the review of other nations shows that countries such as the UK and France require instructors and guides to be qualified and working only within the scope of their qualifications. For the following reasons, this must not be overlooked.

The working environment

A skilled, qualified and experienced workforce is extremely important in the outdoors. This is because instructors and guides often work alone, in 'uncontrolled' workplaces that do not have the immediate safety net of other workers or emergency services and where communications may not be immediate or fully reliable. It is also a dynamic environment where changes caused by weather conditions and the risks presented by height, water and speed all compound the safety management scenario and call for quick decisions and excellent judgement. This sort of judgement and decision-making ability is gained through quality experience as a guide or instructor. It takes years to accumulate and it is difficult to train. Maturity is a significant factor in judgement and decision-making. Many employers prefer 'older' staff if they can get them; others consciously avoid employing young people, but many do not have the luxury of choice.

Skills, pay and retention and their impact on safety and quality of experience

Employers regularly report that they are having difficulty getting skilled staff
New Zealand is highly dependent on a migrant labour force that brings skilled employees from overseas seasonally and on a permanent basis
Pay in the sector is low and working conditions can be poor. Seasonal work, pay per trip, repetitive tasks, long hours, time away from home and family, extreme weather, risk, high living costs in centres such as Queenstown, or life in remote locations all take a toll
Staff retention as a consequence of the above is poor. This is costly in economic terms and gives a poor return on employer investment (and government investment in education)
High staff turnover means that staff are unlikely to be thoroughly experienced in their immediate work situation and environment
Institutional knowledge may be low because people do not stay long enough to either gain it or to pass it on
Staff are often young and inexperienced
Many employers lack the size to have a hierarchy of staff and thus an internal career progression
The high proportion of small businesses means that there is limited capability and capacity for meaningful internal training towards nationally recognised qualifications
The short careers of most guides and instructors means that only a small proportion go on to develop extensive experience and higher skills and qualifications
Working as an adventure guide or instructor is seen by many as fun for a while until you get a proper job.

The impact of poor staff retention on safety, safety assurance and quality of visitor experience

Few employers in any industry would dispute the importance of personal skills when selecting staff, and no more so than in service industries where interaction with clients is a significant part of the job. The training provider expressed that they found it hard to believe that an employer would accept and wish to train someone completely unskilled and unqualified over someone with a nationally recognised qualification.

Research shows that a high proportion of small businesses do not have the internal capability or capacity to train staff (this is why Skills Active ITO and its predecessor SFRITO had difficulty establishing workplace training and assessment in large parts of the sector, and why the NZOIA 'workshop' type of training and assessment model has been so successful and why Skills Active and NZOIA are now working in partnership)
By contrast, good employers already recognise the benefits to themselves and the industry as a whole of supporting nationally recognised qualifications and resent the fact that while they incur the cost of this their neighbours gain financial advantage by not doing so. Good employers want a level playing field. They also want universal standards because nobody benefits from shoddy operators who damage the reputation of the whole industry
Qualifications must be fit for purpose. As in any industry, they cannot be an exact fit with every variation in workplace or activity; rather they provide a benchmark upon which an employer has a responsibility to build through in-house training. In the outdoors this should in all cases be related to operational procedures and internal safety management systems, but is also likely to include technical training at specific sites or in particular activities that are unique to the employment situation

Trained staff versus qualified staff

Recognised national standards are important for safety and quality assurance
Assessment to national standards can only be achieved with any reliability by a registered assessor who has been trained and regularly moderated. Assessment to recognised standards is not an ad-hoc process in any industry
In-house training on its own may equip an employee to operate a particular activity in a specific environment but is unlikely to include the depth and breadth of a nationally recognised qualification. The broader knowledge, skill set and competency of a qualification is likely to better equip an individual to cope with new or unexpected situations
In-house training is not recognised by other employers. It does not enable employees to move from one workplace to another easily and does not reward achievement and competency in a recognised format. It does not help build careers.

In-house training to the exclusion of nationally recognised qualifications is directly linked to high staff turnover and short careers in the outdoor industry, and this is directly linked to safety.

Focus group participants considered that the current New Zealand Qualifications Authority review of qualifications would assist with providing clarity in qualification pathways. Participants also noted that commercial operators and volunteer leaders often have the same level of responsibility and risk when instructing or leading groups. They said that volunteers and commercial operators should be required to meet the same standards and qualifications.

Focus group participants considered that often customers were unclear about what qualifications actually meant in terms of the ability of an operator to provide them with safety assurance.

Qualifications were viewed as a minimum standard and not necessarily an assurance that someone had the skill required to operate in a complex environment.

Focus group participants considered that having a range of standards could potentially devalue standards. They supported the development of a common recognised standard that could be applied across all activities. The essential components of a common standard would be guidance on core skills for risk management, first aid, emergency procedures and group leadership.

The national organisations focus group made the following recommendations:

Qualification alignment is necessary and should be resourced
Information should be made available for the public to assist them to understand what standards and qualifications operators have, what to look for and how to keep themselves safe
There should be a requirement for entry point checks before new businesses commence providing their activities and ongoing external oversight to ensure consistent standards.

One peak safety agency involved in the sector noted that the infrastructure of the volunteer and not-for-profit entities involved in the sector contributed significantly to ensuring safe practice.

It also considered that the National Qualifications Framework should be used as a benchmark for meeting the educational requirements of commercial operators and the not-for-profit sector. It said that this would ensure access and equality to training from the range of accredited providers. It would also reduce potential variation of standards between the commercial and not-for-profit sectors.

The agency noted that current funding constraints have an impact on access and affordability of qualifications and that this has the potential to prevent people in the voluntary or not-for-profit sectors from obtaining qualifications compared to the commercial workforce.

It said that ensuring career and educational pathways were seamless would assist in meeting New Zealand's need for qualified staff and reduce its reliance on recruiting overseas staff over the longer term.

One individual reference group member with extensive experience in industry training commented that the increase in unit standards and qualifications in the outdoor sector has not resulted in a highly trained and skilled workforce. He considered that this was due to the current qualifications funding model being inadequate to cater for the specialist training needed when there were low numbers of participants. He said that, as a result, there had been an increase in 'lower end and easier to obtain qualifications' for activities in which there were high numbers of participants (e.g. rock climbing, kayaking and general outdoor education).

Another individual member of the external reference group who reported that he had been working in the sector for more than 20 years raised the importance of well trained and experienced guides. He noted that badly trained junior guides were far more likely to put clients at risk and that senior experienced staff needed to be valued. He noted:

New people in the industry need quality training by experienced people with good instruction skills. It is not systems and flash equipment that keep people alive. Its high skill level and good judgment in the dynamic environment we work in.... In our risk management the first thing we do is hire the best senior guides we can. Anything you write on paper can not make the trip go better or safer. It is the skill level and their experience of the guides that makes that trip run well.

Appendix 6: Risk profiling

In order to make some determination about the scale of any risk management deficiencies affecting the sector, the working group first undertook high level risk profiling for each activity covered by the review.

The risk profiling work drew on:

Available information about commercial participation in the activity
Available information about workplace serious harm accidents and fatalities that occurred through the activity being offered commercially
Responses to the consultation undertaken for the review (including external reference group advice)
Working group knowledge of the way the activities are delivered and the environments in which they are delivered
Media and anecdotal reports
Other empirical evidence
Professional judgement.

The risk profile for each activity was assessed in three areas:

Risk associated with undertaking the activity
Risk associated with the environment where the activity is undertaken
Risk of the activity to others not undertaking the activity.

For the first two of these risk areas, a set of standard hazards was identified.

For each risk area, a high, medium or low score was allocated based on the extent of hazards that existed in each risk area.

For each activity, an overall risk score (consequence and likelihood assessment) was then allocated. Consequence was scored based on the hazards identified in each of the risk areas. Likelihood was scored using available incident data. This was calculated as a high, medium or low score for the activity.

The working group then ran a 'common sense' check across the overall risk scores but decided not to change any risk scores unless evidence supported such a change.

The working group accepted that, for each activity, the risks associated with different hazards may vary significantly. The risk analysis was therefore approached in a generalised manner with the objective of broadly categorising the risk profiles of various activities, while accepting that many variables exist that may change the profile for individual businesses.

The working group then compared the risk scores for the activities to the type of controls in place for those activities. It noted that the levels of controls across the activities considered by the review could be divided into four broad categories.

These are:

Those activities for which only the HSE Act acts as a safety control
Those activities where the HSE Act is complemented by industry-based guidance
Those activities where the HSE Act is complemented by industry-based guidance and safety agency guidance and perhaps also specific requirements
Those activities for which compulsory and specific guidance applies, including rules-based approaches under other legislation.

The risk levels for each activity considered by the review and the level of controls that applies to them are shown on Table 2 below.

Table 2: Risk levels for each activity compared to level of controls that applies to them.^[27]
Risk level
High	Infrastructural attractions (not covered by other legislation) Luge riding* Sand-boarding	Abseiling Adventure-based learning anyoning Caving Horse trekking Indoor Rock Climbing Mountaineering Quad bike touring* Rock climbing Ski touring	Diving (from vessels >6m & beyond 5Nm of coast) River sledging/ boarding Ski fields Microlight passenger flights* Tandem hang gliding & para gliding* Tandem parachuting* Hot air ballooning*	Diving (from vessels <6m & within 5Nm of coast) Jet boating Rafting
Medium	Events Marine mammal swimming Snorkelling Surfing	Cycle touring* Glacier walking Globe riding Hunting* Mountain biking Walking/ tramping	Bungy jumping Go-karting Infrastructural attractions (covered by other legislation) Motorcycle touring* Para-sailing Sea kayaking Swift water kayaking/ canoeing Water skiing	Sailing
Low	Land-based fishing
	HSE Act only	HSE Act plus industry guidance only	HSE plus industry and safety agency guidance and specific requirements	Compulsory and specific guidance (incl. rules-based approaches under other legislation)
	Low level of control level of control
	Level of current controls

* indicates a special note

Notes on table 2:

The working group recognises that luge riding is conducted on tracks with artificial surfaces and on tracks with natural surfaces and that the level of risk associated with luge riding on each type of surface may be markedly different. The working group acknowledges the very high level of participation in luge riding on artificial surfaces and that there appear to be very few serious harm accidents by comparison
Cycle touring, motorcycle touring and quad bike touring are also covered by compulsory and specific requirements when they are conducted on public roads (adherence to road code rules for cycle tours; adherence to road code rules, vehicle registration and warrants of fitness; and driver licensing for motorcycle touring and quad bike touring)
Participants in guided hunting are also required to hold a firearms licence and abide by the Arms Code
All adventure aviation activities will be subject to the new Rule Part 115 - Adventure Aviation when they are implemented. It is anticipated that this will occur in early to mid-2011.

Accident and injury profile

The following table shows the number of workplace serious harm accidents and fatalities reported to the Department, Maritime NZ and the CAA during the five-year period covered by the review, by activity.

Table 3: Reported workplace serious harm injuries and fatalities by activity type over the five-year period 1 July 2004 to 30 June 2009.
Activity	Reported workplace serious harm injuries 1 July 2004 to 30 June 2009	Reported fatalities 1 July 2004 to 30 June 2009
1. Abseiling	1	0
2. Adventure-based learning	Covered under specific activities
3. Bungy jumping	3	0
4. Canyoning	1	7
5. Caving	2	0
6. Cycle touring	0	1
7. Events (land-based)	Covered under specific activities
8. Glacier walking	3	1
9. Globe riding (plastic spheres)	5	0
10. Go karting	20	0
11. Horse trekking	40	0
12. Hunting	1	0
13. Indoor rock climbing	17	0
14. Infrastructural attractions (extreme rides not covered by other legislation)	7^[28]	1^[29]
15. Infrastructural attractions (extreme rides covered by other legislation)	7^[28]	1^[29]
16. Land-based fishing	0	2^[30]
17. Luge riding	31	1^[31]
18. Motorcycle touring (on road)	0	0
18b. Motorcycle touring (off road)	6	0
19. Mountain biking	11	2
20. Mountaineering	1	4
21. Quad bike touring	26	1
22. Rock climbing	0	0
23. Sand boarding	0	1
24. Ski fields (activities on)	102	0
25. Ski touring	0^[32]	2
26. Walking / tramping	8	1
27. Diving (from vessels <6m/within 5Nm from coast)	6	5
28. Diving (from vessels >6m/> 5Nm from coast)	6	5
36. Snorkelling	1	0
29. Events (water-based)	Covered under specific activities
30. Jet boating	11	1
31. Marine mammal swimming	0	0
32. Rafting (white water)	41^[33]	3
33. River sledging / boarding	1^[34]	2
34. Sailing	0	0
35. Sea kayaking	0	0
37. Surfing	0	0
38. Swift water kayaking / canoeing	4	0
39. Water skiing	0	0
40. Hot air ballooning	0	0
41. Microlight passenger flights	0	2
42. Parasailing	0	0
43. Tandem hang gliding and para gliding	33	2
Totals for period 1 July 2004 to 30 June 2009	382	39

Appendix 7: Principles for operators

Two founding principles

Operators demonstrate a positive safety culture driven by committed leaders

A positive safety culture: The first principle upon which all others are founded, it is characterised by an overt commitment to safety at every level of an organisation; it relies on leaders promoting and adhering to good safety practices, e.g. leading by example consistently.

Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.

Operators have a safety management system (SMS) relevant to their operation

Safety management system: A coordinated and comprehensive set of processes specifically designed to optimise safety performance.

An SMS addresses safety across all aspects of the organisation and includes provisions for recruitment, training, safe communication, well documented standard operating procedures, internal and external assessment programmes, safety reporting, incident reporting, and emergency action plans. An SMS addresses the potential for both systemic weaknesses and active failures.

Six additional 'core' principles

Operators have an external assessment before commencing operations

Initial external assessment: An assessment by an independent third party appropriately qualified to assess and approve the type of activity being undertaken.

Its primary function is to assess the SMS and provide operators with advice and support: is the SMS comprehensive, workable and tailored correctly for that activity? It includes a site visit.

Operations are subject to ongoing external assessments

Ongoing external assessments: Primarily for verifying compliance with approved standards, procedures and/or national standards where available; as with the 'initial' audit, they assess the relevancy and effectiveness of the SMS and provide advice and support to operators. They also include a site visit.

Operators ensure that staff are competent

Staff competency: Organisations ensure staff have appropriate experience supported by relevant training and/or qualifications. Induction training is followed by ongoing training at a frequency and depth that is consistent with the nature of the activity. The correct balance of experienced to less-experienced staff is consciously managed.

Operators clearly communicate the risks involved and responsibilities the clients themselves have in mitigating them

Risk and safety information to clients: prior to undertaking the activity, clients are provided with appropriate risk and safety information in a form and depth that is tailored for the activity, but addresses cross-cultural communication barriers. Client information can be delivered in writing, verbally, pictorially or via a combination of mediums.

Operators have well maintained equipment that is fit for purpose

Well maintained, fit for purpose equipment: equipment and/or infrastructure is subject to regular review under the SMS framework. It is maintained or replaced at intervals that ensure it remains fit for purpose and suitable for commercial delivery of the activity.

Safety information is willingly exchanged externally

Exchange of safety information: organisations make a conscious and formalised effort to share safety information (including lessons learned) with others while externally seeking information that may strengthen their own safety provisions. Commercial interests are pushed aside in the interests of achieving better safety outcomes through shared learning.

Appendix 8: Letter from the Prime Minister

View a large image.

Long description.

^[15]Statistical analysis shows the risk of injury (per operating hour) while engaging in adventure aviation activity is approximately 600 times greater than flying on an air transport/commercial transport flight.

^[16]CAA Aviation Safety Summary Report, 1 July – 30 September 2009

^[17] CAA Aviation Safety Summary Report, 1 July – 30 September 2009

^[18] Note that the Ministry of Transport advises that it is not intending to include parasailing within the scope of the proposed Rule Part 115. Analysis shows that parasailing is a lower risk activity than the other adventure aviation activities. In addition, given that the only commercial parasailing in New Zealand is conducted off vessels which are governed by maritime rules and that Civil Aviation Rule Part 101 specifies requirements for the aviation element of the operation, it is considered that there is no justification for including parasailing within the scope of Part 115.

^[19] Adventure Activities Licensing Scheme.

^[20] OutdoorsMark (launched in 2004) is the national outdoor safety quality assurance programme designed specifically for organisations involved in outdoor education, outdoor recreation, and adventure activities (outdoorsnz.org.nz).

^[21] The International Organization for Standardization is a network of the national standards institutes of some 162 countries, with a central office in Geneva, Switzerland, that coordinates the system and publishes the finished standards (iso.org).

^[22]http://www.adventuretravelnews.com/first-iso-adventure-tourism-working-group-meeting-set-for-october-23-adjacent-to-2009-adventure-travel-world-summit-in-quebec-canada

^[23]Although the main and perhaps only operator of luge rides on artificial surfaces at present has very strong systems audited under ACC’s Workplace Safety Management Practices Programme.

^[24]Coroner Devonport. Mangatepopo Gorge Inquest – Written Findings of the Coroner. 30 March 2010.

^[25] http://www.justice.govt.nz/courts/coroners-court/coronial-services-of-new-zealand

^[26] 19/11/2009, Judge Tompkins, DC Te Kuiti, CRI-2009-073-000065.

^[27]Please refer to the notes on the following page in relation to this table.

^[28] Three arising from flying fox rides and four arising from swings.

^[29] Arising from bridge swinging.

^[30]These involved death of a fishing guide and his client in a hut and may not be fairly attributable to the activity.

^[31]This was on an off-road luge cart track.

^[32] This nil report may be because the accidents were viewed as recreational rather than occurring in workplaces. The New Zealand Mountain Safety Council notes that every winter there are incidents that involve clients and guides getting caught and occasionally buried.

^[33] Most of these appear to be in white water rafting, although two were clearly in black water rafting.

^[34] The low number of workplace serious harm accidents reported may be the result of ambiguity over reporting requirements under the Maritime Transport Act 1994. This has been addressed in the white-water boarding safety guidelines, which specify that operations should have recording and reporting procedures for accidents, incidents and mishaps, which should comply with sections 30 and 31 of the Maritime Transport Act 1994, and the HSE Act 1992.

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Review of risk management and safety in the adventure and outdoor commercial sectors in New Zealand 2009/10 - Final report

VIII. APPENDICES

Appendix 1: Review terms of reference

Background

Purpose

Scope

Definition

Review structure

Governance

Project working group

External reference group

Indicative deliverables and timing

Appendix 2: Methodology

Scoping and establishment

The stock-takes

Consultation

Questionnaires

Submissions from the next-of- kin of people who died in the sector

Discussions with operators and other parties

Comments from the external reference group

National organisations focus group

Gap analysis

Risk profiling

Considering coroners' reports and judges' verdicts

Problem definition

Applying solutions to the different parts of the sector

Options and recommendations

Appendix 3: The New Zealand legislative / regulatory context

Safety management framework applicable to the sector

Agency jurisdictions and jurisdictional matters

Consumer education

Agency resources

Commercial adventure aviation

Commercial jet boating and rafting

Appendix 4: The international context

Size of the tourism sector

Incident rates

Approaches to safety and risk management

Effectiveness of approaches

Current work on approaches to safety and risk management

Appendix 5: Review findings

A. The New Zealand stock-take

B. The gap analysis

Activity-specific legislation or other controls for entry

Guidelines and standards

Qualifications and licences

Safety auditing processes

Relevant associations

C. The consultation

D. What families told us

Themes in families' responses

E. Lessons learnt from fatalities

Review of coroners' reports and judges' verdicts

Key recommendations in coroners' reports

F. Lessons learnt from workplace serious harm accidents

Serious harm accidents

Fatalities

G. Interviews with operators and other agencies

Key themes from the interviews

H. Advice about qualifications, standards, guidelines, training and experience

Appendix 6: Risk profiling

Appendix 7: Principles for operators

Two founding principles

Operators demonstrate a positive safety culture driven by committed leaders

Operators have a safety management system (SMS) relevant to their operation

Six additional 'core' principles

Operators have an external assessment before commencing operations

Operations are subject to ongoing external assessments

Operators ensure that staff are competent

Operators clearly communicate the risks involved and responsibilities the clients themselves have in mitigating them

Operators have well maintained equipment that is fit for purpose

Safety information is willingly exchanged externally

Appendix 8: Letter from the Prime Minister