A Just Culture - What the SEWOL ferry disaster can do to help improve diving performance and safety.

This story has recently hit the news and refers to a British Diving instructor who has been operating in Thailand and one of his students suffered a fatality. Fairly quickly the social media assumed that standards had been breached and he would be in real trouble but then the story has changed slightly today.

I do not know the exact detail of the incident, and to a certain extent, it isn't that relevant to the discussion which will now follow.

Fundamentally people don't normally get up in the morning and make an active decision to operate in an unsafe manner, unless there is a major driver - normally financial or ego drivers.  This figure from Amalberti's "The paradoxes of almost totally safe transportation systems" paper shows this

 

In this area of the world, it is recognised that "safety" is not necessarily the most prevalent trait and that those who can make money the fastest by selling lots and selling cheap are going to be rewarded accordingly, this might be...

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Root Cause Analysis - Kelvin TOPSET Senior Investigator Course

I recently attended a 3-day Senior Investigator Course run by Kelvin TOPSET at Seamill Hydro. This course focuses on the root cause analysis technique using tools developed by Kelvin TOPSET. I was impressed with both the enthusiasm and skill of the tutors in trying to get what can be thought of as quite a simple concept to be practiced in detail.

The course explained the use of the 'Action Card' which is an aide memoire they have developed which covers the key areas that need to be covered to ensure that investigators open their minds and do not fall foul of many of the biases we are subject to.

In total, four simple root cause analyses (RCA) were carried out from incident statement to root cause, and one thorough but time challenging RCA involving a fatality which required the use of interview techniques, examining video and photographic evidence along with reports, with the aim of producing a RCA which could be interpreted without input by a 'CEO'. This detailed RCA certainly...

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