Outcomes are so sexy and attractive…
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...
Predictive Profiling & duiken: “wat afwijkt, verdient aandacht!”
Op 30 mei 1972 zo rond 22:00 uur landde er een Air France vlucht op Lod Airport, tegenwoordig Ben Gurion International Airport, nabij Tel Aviv (Israël). Onder de passagiers die het toestel verlieten bevonden zich 3 Japanse toeristen. Zij droegen ieder een vioolkoffer en zodra zij het luchthavengebouw binnen kwamen, opende zij hun koffertjes. Hieruit kwamen echter geen violen, maar machinegeweren. Zij begonnen willekeurig om zich heen te schieten en wierpen enkele handgranaten terwijl zij van magazijn wisselden. De beveiliging was compleet verrast. De eerste aanslagpleger stierf toen hij per ongeluk door een van zijn compagnons werd geraakt. De tweede stierf toen een handgranaat (vroegtijdig?) ontplofte. De derde werd neergeschoten door de beveiliging en levend gevangen genomen.
Hoe had dit kunnen gebeuren?
De verklaring hiervoor was de start van wat wij nu wereldwijd kennen als het zogenaamde Predictive Profiling. Tot 30 mei 1972 waren in de beeldvorming van de...
Predictive Profiling & diving: “what deviates, deserves attention!”
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...
Le Bon, la Brute et le Truand!
Québec, Canada, l’hiver! Un couple de sportifs se dirigeait de Québec vers le Parc National des Monts-Valin, un paradis pour la raquette. Ils suivaient les indications de leur GPS - Global Positioning System - jusqu'à ce que leur voiture se coince dans la neige… beaucoup de neige. Ils tentent alors de dégager la voiture en pelletant, mais c’est peine perdue… la voiture s’enlise de plus en plus… Ils sont coincés dans une piste de motoneige! Comment cela a-t-il pu arriver? Pourtant, ils suivaient strictement les indications du GPS!
En fait, c’est peut-être la raison… ils suivaient strictement les indications du GPS. Ils se fiaient à leur outil de géolocalisation à 100%, sans se questionner… pire… sans réfléchir. Lorsque l'indication fut de tourner à gauche, ils ont fait confiance au GPS et ont obéi. Ils n'ont pas...
The Good, the Bad and the Ugly!
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...
Perché gli “Avrebbero dovuto”, “...avrebbero potuto” o “Avrei dovuto...” non aumentano la sicurezza in immersione
Quando le cose vanno male, o accadono degli incidenti, è facile identificare come il problema avrebbe potuto essere previsto semplicemente applicando una delle seguenti frasi “Se solo avessero fatto questo...”, “Avrebbero dovuto fare quello...”, “Avrebbero anche potuto fare così...” o “Io avrei fatto...”. Lo facciamo perché stiamo cercando di identificare un modo per poter evitare che la stessa cosa si ripeta in futuro.
È una reazione naturale. Stiamo cercando di porre ordine al disordine ed è nota come ‘ragionamento controfattuale’. Nella sua forma più basilare, pensiamo che se le persone avessero preso delle decisioni differenti, il risultato sarebbe stato diverso. Sfortunatamente, stiamo applicando dei fatti che non esistono ad una storia, per raccontarne una diversa, una con un finale felice.
Di seguito una coppia di esempi di ragionamento controfattuale relativi alle...
Counter-errorism in Diving: Applying Human Factors Training to Recreational Diving
This article was originally published in the Emirates Diving Association magazine on 1 Mar 2020.
There is a growing focus on Human Factors and non-technical skills in the global diving industry, much of which is being driven by Gareth Lock, the UK-based founder of the system described on www.thehumandiver. com. His book ‘Under Pressure’ has helped thousands of people worldwide to take a fresh look at the way they think about diving.
You may be wondering what human factors and non-technical skills are, as it’s not something we talk much about locally.
To demystify these terms, let’s first talk about what they are not. These are not diving qualifications – they are not going to take you deeper or teach you about new diving equipment or diving skills (hence the term ‘non- technical skills’) and they are definitely not ‘just another cert card’ to add to your collection.
Non-technical skills are all about improving decision...
I test pre-immersione e le liste di controllo non sono sempre sufficienti a prevenire problemi legati all’attrezzatura!
Uno dei concetti chiave che insegno è che la sicurezza non è necessariamente l’assenza di rischi od incidenti, ma piuttosto la presenza di barriere e difese che permettono al sistema di fallire in sicurezza. Questa definizione arriva da Todd Conklin, un ricercatore e professionista che lavora nell’ambito della sicurezza e delle performance umane nell’industria americana. L’idea è che si sviluppino delle capacità tecniche e non tecniche, che si creino attrezzature, procedure ed addestramenti e che si gestisca la situazione così che si possano affrontare rischi ad un livello gestibile. Tuttavia, non possiamo creare o gestire qualunque cosa in anticipo, quindi dobbiamo essere in grado di affrontare gli eventi imprevisti e poi condividerne le storie, in modo che anche gli altri possano imparare.
Nelle immersioni con il rebreather, uno dei modi migliori per accertarsi che la macchina sia pronta e sicura è di...
CCR pre-dive checks and checklists are not always enough to prevent an equipment-based accident!
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...
How safe is your diving?
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...