Published Articles
X-Ray Magazine #71 (Feb 2015) - The Application of Non-Technical Skills to Recreational and Technical Diving
...You might think that such skills are not needed in a recreational environment, partly because it is a fun activity, but also because there are no social or organisational structures present to require such skills. If you think this, consider all of the accidents and incidents that you know of and think through what the contributory factors were. How many of them could have been prevented by having (effective) non-technical skills, a clearly communicated plan before getting in the water, making and executing sound decisions when changes happened, noticing how things were changing, but no one wanted to (or could) say anything? Is it any wonder that “human factors” and “human error” rank so highly when it comes to diving incidents or accidents if non-technical skills are not taught?...
The Diver Medic and Aquatic Safety Magazine #7 (Feb 2015) - The Application of Non-Technical Skills to Recreational and Technical Diving (page 45 onwards)
...If we now consider recreational and technical diving, how many accidents or incidents are actually down to the equipment technically failing in an undetected or uncontrollable manner? From my own research and that contained within the literature, very few considering the hundreds of thousands or millions of dives which take place every year. The common factor is the ‘human’...
Pre-Accident Investigation Podcast Episode 54 - SCUBA Diving, Risk, and Safety Differently - Podcast Link
Gareth Lock is a technical diver who has a keen interest in understanding how human errors manifest themselves in the sport diving arena. He has used his experience and knowledge gained as both a ‘Flying Supervisor’ and a ‘Tactical Flight Instructor’ to apply ‘Human Factors’ techniques from military aviation to improving diver safety. Gareth and Todd discuss the journey from Aviation Safety to Diving Safety and everything in between. This is a great podcast.
The Challenges Faced and the Successes Achieved in Delivering Well Operations Crew Resource Management in a Multi-Cultural Offshore Environment - IADC HF Conference 2015 Presentation and Paper
In late 2014, Critical Team Performance started a training intervention of sixteen 10-day training & coaching WOCRM sessions, specifically focusing on supervisors using IOGP Doc 502 as the basis for course content. These sessions took place over an 8-month period with 1 Operator, 4 drilling rigs, 3 drilling companies and 16 shifts from a multitude of nationalities, cultures and experience. Most research examining WOCRM has been carried out in single cultural environments e.g. the North Sea where there are few barriers to communication and learning. This paper will highlight the challenges faced and successes won when delivering training to more than 20 nationalities, with roles from rig superintendent, through DSV and OIM, to the ACOs and ADs, and where English was not the first language for most participants.
The Diver Medic and Aquatic Safety Magazine #6 (Nov 2015) - Single Cylinder Entanglement - Page 64
This month's case study concerns a diver with a safe attitude who, through peer-pressure and a desire to please their instructor, found themselves in a very dangerous situation. It nearly cost her her life.
The Diver Medic and Aquatic Safety Magazine #5 (Aug 2015) - Learning from Experience - Out of Dil on CCR - Page 60
This incident involved an experienced diver having an issue on descent to a deep wreck due to running out of diluent, this is despite them using a checklist. The analysis shows that having a checklist isn't enough, it needs to be followed correctly and diligently, otherwise incidents will happen.
Divers Alert Network Alert Diver Magaine (Q3 Summer 2015) - A Culture of Active Risk Management
As we seek to enhance the culture of safety in scuba diving, we cannot just import the experiences, practices and processes from aviation and other domains with established safety cultures. As a recreational activity with no single organization responsible for its direction or regulation, diving cannot readily incorporate the lessons we can learn from more organized frameworks. This is particularly true because some level of risk is an essential part of our enjoyable and challenging sport.
Human Factors in the Oil and Gas Industry - Oil and Gas IQ Jul 2015
Many people believe that human factors is just about ergonomics, but it is much wider than that. It is “concerned with optimising the relationship between people and their activities, by the systematic application of human sciences, integrated within the framework of systems engineering.” Over the years, technical solutions to problems have been developed and incorporated and they are no longer the key focal point when it comes to recommendations following an adverse event. Instead, it is the human in the system that is being looked at as a means of improving performance and safety. This first of a series of articles at Oil and Gas IQ about the role of HF and CRM in the oil and gas sector.
The Diver Medic and Aquatic Safety Magazine #4 (May 2015) - Case Studies on Decision Making
The following two case studies will show that decision-making is never as easy as we think it is, and why we sometimes make bad decisions that end up as an incident or a fatality.
Incident 1: Switching the O2 cylinder off on MCCR whilst in-water - Hypoxic Event
Incident 2: Lost inside a wreck at 45m - a chain of events
Those involved in aquatic safety sometimes wonder why people made the ‘stupid’ decisions they make as the choices were obvious. Unfortunately hindsight bias means that we already know what the outcome was. Furthermore, we forget that those involved in incident only have the information available to them at the time whereas afterwards those examining it, have much more! Incidents are rarely caused by simple linear decisions, they are a network of contributory factors which are normally only apparent after the event and therefore we should be careful not to judge right or wrong.
#66 X-Ray Magazine (Apr 2015) - Is Diving Really Safe?
Admittedly a rather contentious title, but it’s supposed to be. Debates over whether diving, or even certain types of diving, are safe sometimes get emotive and heated, depending on the arguments being made. These include: Is closed circuit rebreather diving safe? How much safer is recreational rebreather diving than open circuit? Is cave diving safe? Is recreational diving to 18m on open circuit safe? The simple answer is—it depends! This article will present a series of arguments so the reader (and diver) can make that decision, as ultimately, it is the diver who is choosing to get in the water and expose themselves to the risks therein. The article will cover some essential definitions and then outline where responsibility could or should lie when it comes to undertak- ing a “safe” or “unsafe” activity.
#65 X-Ray Magazine (February 2015) - Decisions, Decisions, Decisions - Why we make good or bad decisions.
There is a significant body of evidence which shows that divers involved in diving incidents often make poor decisions— sounds obvious, doesn’t it? So if it is so obvious, why do we continue to make them? Simple decisions such as continuing a dive when they should have ended it, choosing the ‘wrong’ gas for narcosis/density/decompression reasons, wearing the wrong thermal protection for the conditions, diving with the ‘wrong’ buddies, the list goes on. This article will cover how we make decisions, and more importantly, why we make poor decisions and the pitfalls we encounter when doing so. We won’t always be able to stop ourselves making poor decisions, but if we can recognise when we are likely to make them, we can at least try to put controls in place to check ourselves.
The Diver Medic and Aquatic Safety Magazine #3 (Feb 2015) - Case Study on OC Trimix Diving - Fatal
“The dive computer recorded an ascent from 54 metres to the surface in less than two minutes.” - In many cases, reading an account of an incident provides us details that we think would be obvious at the time if we had been in the dive, and so we question why the diver couldn’t spot what was going to happen. But hindsight does make it easy to spot the weak points in a scenario; it’s easy because the outcome is already known. That’s too late for the diver who lost his or her life. Yet providing case studies allows readers to improve their own knowledge or experience ‘bank’, so that when they come across a similar situation, they are better informed. This allows for more robust decisions. Learning from mistakes is how we improve; we just need to make sure that those mistakes are survivable.
#63 X-Ray Magazine (October 2014) - Reporting Culture - Improving Diving Safety
“...The real reasons people don’t provide a higher level of detail are two fold: privacy and legal culpability” was the response recently when I posted a blog (http://cognitasresearch. wordpress.com/2014/08/26/ the-devil-is-in-the-detail/) about the need to collect more detail when looking at diving incidents so that the community, the agencies and academia can understand WHY incidents happen. Just knowing what happens is not enough to come up with strategies (personal or corporate) to prevent incidents from occurring in the future. We need to be able to raise the awareness and knowledge of those involved in the sport so that they can truly take responsibility for their own actions. Sticking a note in the manual saying that diving is dangerous or on the back of a CCR which says, “This unit can kill you if improperly used”, are not enough. That’s like saying “Drive safely to work” to your partner as they set off in the morning.
The Diver Medic and Aquatic Safety Magazine #1 (August 2014) - Safety Culture - Evolution or Revolution?
Since the Second World War there has been interest in how pilots interact with their aircraft with a view to improving safety. This followed a number of accidents where pilots made the wrong selection due to similarity of landing gear and flying control surface levers. This research moved on from just physical interaction with the aircraft controls, and included crew behaviours, how crews dealt with their tasking authorities and the commercial or operational pressures to undertake a task, and how safety was influenced by all of this. Over time, this work developed further into other areas such as nuclear power plants and other high reliability organisations, where it was realised that there was no way a single person could monitor everything going on, and that supervisory or organisational issues were having an influence on operational outputs and safety at the individual level.
#62 X-Ray Magazine (August 2014) - Just Culture - An Explanation of What It Is and What It Isn't
A diver had an oxygen toxicity seizure because an incorrect gas was filled in a cylinder by a dive centre. A baby died because the wrong dose of medication was injected. Who is to blame for the error and how do we try to make sure that these types of incidents aren’t repeated? This is the second article in a series of six looking at a safety culture and its component parts, and focuses on a just culture, the aspect of a safety culture which underpins everything. Some of the readers may remember an article I wrote on this subject a couple of years ago, but this one will go into much more depth and give examples of the issues faced in both the scuba diving community and other environments, which have more established safety management system programmes and cultures.
#61 X-Ray Magazine (July 2014) - Checklists - A Tick in the Box
At the Rebreather Forum 3 conference held in Florida in May 2012, a number of presentations were made which advocated the use of checklists as a means to prevent diving incidents from occurring, or at least reducing the likelihood of occurrence. Consequently, there was a consensus opinion made at the end of the conference that checklists should be more actively promoted by both the manufacturer and the training agencies and should become the norm. Significantly, there should be overt use by senior members of the diving community in the same way that leading figures in snowboarding and skiing have changed the attitudes over the use of helmets, with the result that it is ‘not cool’ to not wear a helmet. To further emphasise the endorsement of the use of checklists, at the 2014 TEKDive USA held in Miami from 17-18 May 2014, PADI provided T-Type CCR checklists for all attendees in the delegates’ bags.
#60 X-Ray Magazine (June 2014) - Safety Culture - A Follow Up
In August 2012, I wrote an article which discussed just culture and what this meant in the con- text of recreational and technical scuba diving, and using this concept, how we can improve diving safety. The main thrust behind the article was that everyone makes mistakes, irrespective of who we are in the diving community, what our experi- ence levels are or what qualifications we hold. To improve learning, we need to stop throwing rocks at those who have the courage to discuss their incident in a public forum or report it to DAN, BSAC or DISMS. Sure, many people make silly mistakes or poor decisions, which ultimately cost them their lives. But those individuals didn’t get up that morning thinking, “I know, today appears to be a good day to die.”
Quest Vol 15 Edition 2, Journal of Global Underwater Explorers - The Use of Checklists in Rebreather Diving.
#50 X-Ray Magazine (August 2012)- Safety Culture - An Introduction
“Thank [beep] for that! How lucky were we? We better not do that again. Don’t tell anyone though, we don’t want to look like amateurs...”
This was a mistake that could have cost them their lives, but fortunately, the divers spotted it and corrected the issue before it went too far. The current culture we have in diving means that the probability of the divers telling anyone outside their buddy pair, or maybe the divers present on the boat, is pretty much zero.
The problem with not letting people know what happened is two-fold. Firstly, others can’t learn from your mistakes; and secondly, the ‘authorities’ don’t obtain the evidence to show that there is a problem with whatever it was that went wrong.
An article examining the challenges faced in diving with trying to improve safety, or manage risk more effectively, if we don't have a Just Culture in place.
