In the mid-1980s, there was a flight safety film produced which showed a Royal Air Force pilot walking out to his single-seat Jaguar fighter aircraft for a training sortie. He prepares the aircraft, starts it up and takes-off down the runway. Unfortunately, the aircraft has an engine failure immediately after take-off, but the pilot can’t jettison the external stores, and crashes and he dies because the aircraft doesn’t have enough power to fly on a single-engine given its full fuel load and the heavy external stores. It transpires that during the pre-take-off checks, the pilot forgot to arm the stores jettison system, and even though he is trying to jettison them, they won’t go because there is a safety system in place to stop an inadvertent release. It would be quite easy to blame this highly trained and professional pilot for forgetting to do something which was part of his pre-take-off checklist. However, the Royal Air Force recognised that it takes many things...

A short while ago Gareth asked me to write a blog for this website, as a newly qualified Human Factors in Diving Instructor. We talked about a subject and all seemed ok. But try as I might, I just could not explain the topic as eloquently as I wanted. So, we had another chat and I tried a different theme. Same result. The problem was that no matter what I wrote, I just didn’t feel it matched up to what Gareth and the other new instructors had written. And that’s when it hit me- I was out Human-Factoring myself.

I’ve been instructing various sports for twenty years and consider myself to be a capable and cautious instructor. I’ve been teaching diving for ten years, so you think by now I’d be quite happy with my level of knowledge. But that’s the thing; almost every time I step foot into the classroom, I’m waiting for someone to call me out, to realise that I actually don’t have  clue what I’m talking about and I don’t...

On 30 May 1972 around 22:00 hours an Air France flight touched down at Lod Airport, now known as Ben Gurion International Airport, near Tel Aviv (Israel). Amongst the disembarking passengers were 3 Japanese tourists. Each of them carried a violin case and as soon as they entered the terminal building, they opened these cases. Instead of violins, they took out machine guns. They started shooting indiscriminately and also threw hand grenades as they changed magazines. Security was completely taken by surprise. The first attacker died when he was accidentally hit by one of his accomplices. The second one died when a hand grenade exploded (prematurely?). The third attacker was shot by security forces and captured alive. 

How could this have happened?

This was seen as the start of the so-called Predictive Profiling. Until 20 May 1972 all terrorists, at least in the mind of the Israelis, were Arab. This meant the focus was on people who looked...

Quebec, Canada, Wintertime – A couple of young people were driving from Quebec City to the Parc National des Monts-Valin, a paradise for snowshoeing. They were following the directions on their GPS - Global Positioning System - until the car got stuck in the snow… lots of snow. They tried to shovel it, but it just got worse… They were stuck on a snowmobile trail! How could this have happened? They were strictly following the indications of their GPS! 

Maybe that is the reason… they were strictly following the indications of their GPS. They were relying on the geolocation tool 100%, without any question… worse… without any thinking! When the directive was to turn left, they trusted the tool and obeyed, and they did not notice the changes in the road pavement that was becoming completely covered by snow, nor the red and blue poles that had appeared on the sides of the road for the past 3 km, marking the snowmobile trail. When they...

One of the key themes I teach is that safety is not necessarily the absence of accidents or incidents, but rather the presence of barriers and defences and the capacity of the system to fail safely. This quote comes from Todd Conklin, a researcher and practitioner working in the safety and human performance industry in the US. The idea is that we develop technical and non-technical skills and design the equipment, procedures and training and manage the environment so that risk is managed at an acceptable level. However, we can't design or manage everything beforehand, so we need to be able to handle those 'odd events' and then share the stories so that others may learn. 

In rebreather diving, one of the best ways to ensure that the unit is safe to dive is to make sure that the build and final pre-dive checks are completed. However, even if this is done diligently on the surface including packing the scrubber and then executing the complete set of final checks, things can go...

What does safe mean to you? The dictionary defines safe as “protected from or not exposed to danger or risk; not likely to be harmed or lost” and in the context of diving, we often think about the physical risks. These can include decompression sickness, animal-induced injuries, separated from the team/boat, entanglement, lost within a cave system or running out of gas. These are all credible negative outcomes which we should be concerned about. In fact, a number of these appear in the 2008 research paper from DAN (Common causes of open-circuit recreational diving fatalities) which examined triggers, disabling event/injuries and causes of death in diving, and so they should be definitely considered as part of our risk management plans and diving plans.

 
But what about another form of safety? A form which Google under project Aristotle identified as the key trait of high-performing teams and without which nothing else really mattered. A form...

It would be difficult to imagine a life that didn’t involve goals. Goals provide inspiration, direction and motivation for nearly everything we do. Goal setting is responsible for nearly all the amazing things that we do, from walking on the moon to diving into the Marianas Trench. In a simpler form, goals get us out of bed in the morning and help us put food on our table. Goals and goal setting are synonymous with human nature and part of who and what we are. Indeed, goal setting is almost always viewed as a positive act on our part and something that drives us to accomplish things.

Goal setting also has a darker side and one that can lead us into trouble. In his book “Destructive Goal Pursuit”, D. Christopher Kayes reviewed the events surrounding the tragedy on Mount Everest in 1996 where experienced mountain guides Rob Hall and Scott Fischer led teams of climbers in a summit attempt of that mountain that ended in disaster. Eight climbers perished in this tragedy...

It was 04:00 and I woke up with a dull pain in my left forearm and pins and needles in my left hand. Bugger!

The Dives

That day I had completed two dives, the first to max depth 44m with an average depth of 38m for 27 mins and completed 31 mins of deco using 50%. The second was to a max of 26m, average 23m for 43m and a min deco ascent with deco clearing at 6m. Surface interval was 3 hours. An uneventful pair of dives from a decompression point of view. The previous day (Tuesday) I had not dived, the day before that (Monday) I only did 50 mins at an average of 21m with 10 mins on 100% O2 at 6m.

For those who are looking for a reason as to my bend, sorry, I don't have one and to be honest, the mechanism and causality for the bend is uninteresting to me in this particular case. Neither of the hyperbaric doctors here in Stromness could explain it either.

Rather, this blog is more about the decision-making processes that happened after I woke up because I believe that most divers...

Many of my readers will have heard about me talk about Professor James Reason's Swiss Cheese Model and how it can be used to show how incident develop because of holes in the barriers and defences which are put in place to maximise safety.

Professor Reason's research showed that at different levels within a system, there are different barriers or defences present. e.g. organisational, supervisor and individual. However, these defences can have holes in them because the organisations, supervisors and operators are all fallible and therefore the defences cannot be perfect.

• At the Organisational level, these failures might be poor organisational culture, inadequate diver and instructor training programmes, flawed equipment certification systems e.g. CE or ISO, or misunderstood/misused reward or punishment systems e.g. QC/QA or certificates for the number of certifications completed.
• At the Supervisor level, these gaps might be inadequate supervision dealing with inexperienced...