SH24: Don't just focus on the errors

In this podcast episode, we explore the concept of human error in diving and how it relates to different types of errors, including slips, lapses, mistakes, and violations. The episode highlights that errors alone aren't the primary issue; they need to occur in a specific context where hazards and control/mitigation measures are present to impact safety. Using a real-life example from the "If Only" documentary, the podcast discusses how various factors, such as time pressure, equipment issues, and social environments, can contribute to catastrophic outcomes when combined with errors. It introduces the "TWIN" or "WITH" model, which categorizes error-precursors into four areas: Work Environment, Task Demands, Individual Capability, and Human Nature. The episode emphasizes the importance of understanding these error-precursors to enhance dive safety and prevent adverse events. It also encourages divers and instructors to proactively identify and address these conditions, highlighting the role of context in diving incidents and accidents.

 

Task Demands

Time pressure (in a hurry)

High workload (large memory)

Simultaneous, multiple actions

Repetitive actions/monotony

Irreversible actions

Interpretation requirements

Unclear goals, roles, or responsibilities

Lack of or unclear standards

 

Individual Capabilities

Unfamiliarity with task/first time

Lack of knowledge (faulty mental model)

New techniques not used before

Imprecise communication habits

Lack of proficiency/inexperience

Indistinct problem-solving skills

Unsafe attitudes

Illness or fatigue; general poor health

 

Work Environment

Distractions/interruptions

Changes/departure from routine

Confusing displays or controls

Work-arounds/OOSß instrumentation

Hidden system/equipment response

Unexpected equipment conditions

Lack of alternative indication

Personality conflict

 

Human Nature

Stress

Habit patterns

Assumptions

Complacency/overconfidence

Mind-set (intentions)

Inaccurate risk perception

Mental shortcuts or biases

Limited short-term memory

 

Original blog: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors

Links:

HF for Dummies Part 2- Human Error: https://www.thehumandiver.com/blog/hf-in-diving-for-dummies-part-2-human-error

‘If Only’ Documentary: https://www.thehumandiver.com/ifonly

Normalisation of Deviance blog: https://www.thehumandiver.com/blog/normalisation-of-deviance-not-about-rule-breaking

Institute of Nuclear Power Operations reference guide: http://nuclearsafety.info/wp-content/uploads/2010/07/Human-Performance-Reference-Manual.pdf

Tags:

English, Decision-Making, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting