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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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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Can divers learn from the US Forest Service?

The US Forest Service (USFS) operates in a highly dynamic and high-risk environment. Changes can happen which can have catastrophic circumstances if they are not picked up. Unfortunately, sometimes things do go wrong and firefighters die or large amounts of property is lost. However, the USFS recognises that failure is a learning opportunity irrespective of what the outcome was. They also believe that exactly the same circumstances are unlikely to appear again so fixing that exact same problem will have limited impact on operations. However, there are probably other gaps in their safety protocols that need to be identified and fixed and that is the purpose of a Learning Review.

Given that we have so many ‘similar’ accidents, I believe that the same 'learningt fom failure' mindset should be developed within the diving community - that was the motivation for this article.

The US Forest Service (USFS) published a document in 2014* outlining how they undertake...

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"Human Error" or "Diver Error": Are they just an easy way of blaming the individual?

Human error is normal. Human error is part of the way we learn. It is almost impossible to remove human error from any system. Therefore, 'Human error' should not be the conclusion of an investigation. If it is, then we are not likely to improve the situation for the future. Depending on the outcome of the error or errors, the impact can be minor or it can be fatal, the problem is we don't necessarily know the scale of the issue until after the event.

In the last blog I covered the basic concept of a Just Culture and why it is essential to have this if we are to improving safety. We need to be able to talk about the errors or violations (at risk behaviours) that occur, and the reasons why it made sense to us at the time if we are to improve performance and safety, and reduce the likelihood of the same adverse event happening again. In this blog I am going to talk about 'human error' and the differences that exist within this overly-simple classification. The next...

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Incompetent and Unaware: You don't know what you don't know...

diving human factors safety Apr 28, 2016

This is a summary of my presentation at TekDiveUSA as recordings weren't allowed. The interactive presentation was just short of an hour so this is a bit of a long post!!

The simple premise is that we don’t know what we don’t know. Even worse, we don’t that we don’t know!! This double hit in competency was highlighted by a couple of social researchers Dunning and Kruger when they undertook a series of experiments to assess what their subjects thought of their own knowledge. The exams covered logic, humour, and grammar and showed how prevalent the problem was.

The images below show the issue at hand. Pretty much everyone thought that they were above average (60-70% scores), but not exceptional. However, if you look at those who scored in the bottom quartile, the lowest scores were in the order of 12-15% even though they thought they scored 55-60%. The other noticeable part was that those who were well above average underestimated their abilities. However,...

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It's the little things that catch you out...

Humans like to do things efficiently, or as some call it, cutting corners. The problem is that when the configuration changes and the diver cannot recall the 'situation' and it bites, it sometimes ends up with a dead diver. 

Complacency is a term often used as one of the key factors when it comes to diving fatality reports. The problem is that complacency is only really apparent after the event because we have had something occur that shows us how far we are from the ideal. The same mental developmental processes which allow us to operate efficiently are also the same processes which can lead to an accident. Complacency can be summed up as the difference between the perceived model of the world and the reality of the situation. To save time, humans create models of expectation of what is happening around them so that we don't have to process vast amounts of information. If nothing changes, we run that mental model making assumptions about what will happen in X...

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What relevance does Human Factors have to recreational and technical diving?

A comment I often get is "How relevant is Human Factors to my diving and why should I care? I haven't had an accident so far, so I (we) can't be doing anything too wrong"

This is a fair comment but consider that high risk organisations have learned the hard way: using the premise that evidence from the past to determine behaviours in the future can lead to some very bad outcomes. Consider the following examples:

  • NASA and the Challenger and Columbia disasters - doing the same things and edging further from accepted standards, a normalisation of deviance, aterm coined by Diane Vaughan. That's a pretty big organisation.
  • An Executive Jet crew who forget to remove the gust lock from their jet which meant they couldn't move the control column subsequently crashed at the end of the runway killing all onboard? 
  • A general aviation pilot who didn't drain the water from his fuel tanks as part of the standard operating procedures and crashed? 
  • The students and...
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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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Big Data - Use as a Predictor? Or Not?

safety safety culture Dec 22, 2015

I love reading articles like this http://www.nytimes.com/2014/04/07/opinion/eight-no-nine-problems-with-big-data.html?_r=0 because it both prompts positive thought (how to make it work) and at the same time reinforces the complexity of the environment we live in, especially when it comes to developing leading factors to improve safety and performance.

Most people are aware of the linear view of causality (if this, then that) and in a number of scenarios, it is indeed applicable. However, the majority of incidents and accidents involve humans and as a consequence I believe that this linear view is too simplistic.

My opinion is that it should be considered more like an object that requires a critical mass of contributory factors before the adverse event happens. Unfortunately, we aren't particularly great at spotting where those little bits and pieces are coming from to make up that critical mass. Sure we can spot the big ones, but you can get the same effect if you add lots and lots...

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Violations are common...So don't be surprised when people break rules

"An online survey drawing on 50 key offshore companies saw 34% of respondents saying their company needed to offer additional operational and technical training. Worryingly, 50% found it difficult to say ‘no’ to a client or senior staff demanding actions that might compromise safety. Some 78% of respondents believed that commercial pressures could influence safety." - Original Article referring to OSV and Workboat, 2015,

"78% of the study population [offshore workers] have either reported violating or will have no problem with violation when the time comes. Only 22.5% remain with a reasonable guarantee that they have not or will not bend the rules." - Hudson et al, (1998). Bending the rules: Managing violation in the workplace.

Given the above, it should come as no surprise that people break rules in the workplace. Humans are creative, and in the main, want to get work done as efficiently as possible, which means they sometimes circumvent the safety measures or rules in...

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