When the holes line up...

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...
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The Dirty Dozen - Part 1

Introduction

Ever looked back at an incident or accident to find the reason it happened and realised that you were stressed, tired or distracted and that is what caused the event? These are three of the ‘Dirty Dozen’ which human factors experts have identified as key contributory factors or precursors to incidents and accidents.

The term ‘The Dirty Dozen’ refers to twelve of the most common human error pre-conditions or precursors which lead to accidents and incidents. These twelve have been shown to influence people to make mistakes, errors or violations. The concept was developed by Gordon Dupont in 1993 and is now a key element to Human Factors in Maintenance training.

Note that these twelve are not the only factors which lead to mistakes, errors and violations, but they certainly give you a focal point to identify conditions where errors and violations are more likely to occur. Different domains or even subsets within domains like pilots, ramp crews, air...

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Only 20% of surgeons would like to use a checklist in their operations…

…but 94% would like one used in an operation on themselves…!
 
Atul Gawande gave four presentations before Christmas as the 2014 Reith Lectures’ presenter (BBC iPlayer downloads and transcripts can be downloaded from here).
 
During these presentations, he highlighted ways in which the healthcare and medical industries could develop their safety further, but he also recognised that we are all human, fallible and therefore there was a limit to what could be achieved and, consequently we needed to recognise this when judging adverse outcomes.  The same situation needs to be recognised within sports diving where we are undertaking an activity (of our choice) which has an inherent risk of fatality as we are in a hostile, non-life sustaining environment if something serious goes wrong.
 
His second presentation specifically looked at how better systems could improve safety, and radically reduce the mistakes and errors made, and improve...
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'Choices': Guaranteed small loss or a probable larger loss, injury or fatality?

You have been blown-out for 4 weekends in a row and you now have an opportunity to dive this weekend as the weather is fabulous and the visibility has been reported as 10m+. However, you aren’t due to dive for another four weeks for a variety of reasons. Just as you getting your gear ready to put on, you notice that you have a malfunction with your gear, something manageable but will cause you additional workload and reduce your margin of safety on the dive. This is a failure you wouldn’t normally accept because you get to dive lots. If you don’t dive, your buddy will have to sit out too as there isn’t anybody else to dive with them at such short notice. What do you do?

At this point, you are managing uncertainty not a risk because the numbers are not calculable. You decide to dive and nothing adverse happens and you have an awesome dive.

Are you reflective of your management of uncertainty? Did you think it was ‘good’?

But what if two or three...

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Dive safety leads to nothingness...and nothingness is unemotive!

How safe are you when you dive and how do you measure safety? Think about the following story and how safe the situation was...

Six divers had decided to undertake a 30m dive from a RHIB. John and Dave were diving as a team with their local university dive club and had over 2000 dives between them. Graham was relatively newly trained as a marshal and had not worked with Brian before. On the dive boat, there were two new divers to the club, Gail and Mark. Both Gail and Mark had successfully completed a check-out dive & dry suit familiarisation course with another instructor in the club, and they were already certified for 40m diving. Graham was keen to do a drift dive in 32m of water. Brian, the cox, was somewhat worried about the conditions as there seemed to be waves forming. However, as long as all divers were certified to 30m diving and effective at getting into the water and back onto the RHIB, he was happy that the risk was acceptable. To allow the Cox and Marshall to...

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Why ‘everyone is responsible for their own risk-based decisions’ isn’t the right approach to take to improve diving safety.

A diver qualified in the summer of 1999 while on holiday in Greece. His final dive on his PADI Open Water course was to 25m, obviously beyond the standards of this course. The instructor told him to write 18m in his logbook as they were only supposed to go to 18m. The diver didn’t know this during the dive so didn’t question the depth they dived to. Nor did they know that there was a way of providing feedback to the agency for breach of standards. In March 2005, the diver went to Cape Town with work and there was an opportunity to dive at Gansbaai so he took his OW card with him. He hadn’t dived since his OW course in 1999. There was no checking of cert cards when they got there, nor was there a skills dive to ensure everything was ok. The diver and 3 of his buddies completed a 45min 10m dive from a RHIB with no problems.

One month later the diver was in San Diego, again with work, and wanted to go diving. He had decided that one of the most important things he...

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Cognitive Dissonance - Why you are right and I am wrong...Or are you?

"A man with a conviction is a hard man to change. Tell him you disagree and he turns away. Show him facts or figures and he questions your sources. Appeal to logic and he fails to see your point." -  Leon Festinger

Cognitive Dissonance has been defined as the psychological pain of accepting facts which are counter to our views which then prevents an open and rational cycle of improvement.

Recently I re-read Black Box Thinking by Matthew Syed (a book I’d thoroughly recommend). The book uses aviation safety as the premise for improving patient safety by looking at the ways in which data has improved the former - the data from aircraft black boxes and cockpit voice recorders showed investigators what the pilots saw and experienced and how it could have made sense to them at the time, despite what hindsight bias and outcome bias would them to believe. Furthermore, data from the aircraft systems would allow reconstructions to take place in the simulator to see lessons...

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Just another brick in (under) the wall...taking action

If you want to do something new which improves your safety or performance, how committed are you? If you see something shiny, how easy is it to buy that compared to making a change to your habits or behaviours? Which is likely to have a greater effect on your diving?

Three weeks ago I met Isabel, a business coach specialising in branding and marketing, with a view to working with her. She had been recommended to me as a coach who has the knack of pulling coherent ideas from the free-flowing discussions and coming up with a clear message regarding an offer, branding and identity.

As Isabel and I sat there waiting for our coffee to cool down and talking about the future, she asked me a really important question. “On a scale of 1-10, how committed are you to making a difference to your business so that you can grow and get to where you want to be.” 

I said "9". I also added that given the time I put into developing human factors and non-technical skills...

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Safety is not _the_ priority...

human factors safety Apr 14, 2018

This might be surprising for many, but safety is not the priority which organisations and individuals have to consider when diving. Both organisations and individuals have to balance a number of other priorities including time, money, reward, resource, productivity, results, fear of litigation and legislation all within a context which is not static, but rather is dynamic and evolving.

What does ‘safety’ mean anyway?

The International Civil Aviation Organisation (the international regulatory body responsible for aviation safety) has defined safety as “The state in which the risk of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management” in their ICAO Safety Management Manual. The bolding is mine to highlight that there is a need to understand what an acceptable level of risk actually is.

So how do you define ‘risk’?

In 1983...

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What does Human Factors in Diving mean?

human factors Apr 13, 2018

Human factors can be a bit confusing to many people, and there is a really good reason for that. Read on and find out why. 

"Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance."

International Ergonomics Association 

The model below shows how human factors covers everything from how you press  buttons on a controller through to the dimensions of a culture and how people think others should behave when someone senior says something (power distance).

 A model showing the breadth and depth of human factors

Steven Shorrock wrote a great series of four blogs recently which highlighted the fact that human factors could be considered to be made up four parts which overlap to some degree (Shorrock) and it...

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