Counter-Errorism in Diving: Applying Human Factors to Diving

In this podcast episode, Gareth shares his insights from a presentation given to young CEOs and presidents during a diving trip, focusing on applying lessons from diving to non-diving environments. The discussion encompasses topics like organizational drift, competing goals, creating a shared mental model using non-technical skills, and fostering an environment supporting psychological safety and a Just Culture. The key takeaway emphasizes the importance of learning and practicing debriefs for future dives, with a focus on the DEBrIEF framework. The framework is detailed as a valuable tool for analyzing both positive and negative dive experiences, promoting a psychologically safe environment for effective debriefing. Each element of the DEBrIEF framework is explained, from defining the scope and creating psychological safety to reviewing the timeline and fostering internal and external learning. The episode concludes by highlighting the framework's role in continuous development for high-performing dive teams and the importance of a positive and supportive learning environment. The standalone DEBrIEF guide is also made available for further reference. Original blog: https://www.thehumandiver.com/blog/debriefing   Links: DEBrIEF guide: https://www.thehumandiver.com/debrief   Tags:  English, Debrief,Gareth Lock, Leadership, Teamwork

In this podcast episode, the focus is on a scenario involving three teams of divers tasked with finding a wreck in challenging underwater conditions. The problem requires a mix of decision-making and situation awareness, emphasizing the importance of understanding the current situation, recognizing patterns, and projecting ideas into the future. The teams face challenges such as maintaining a constant bearing and dealing with variable currents. The experienced divers demonstrate the concept of intentional deviation, choosing a longer route to increase the chances of finding the wreck. The episode highlights the application of human factors and non-technical skills in diving, showcasing how intentional decisions, though seemingly flawed economically, can be smarter in the given context. The interdependence between technical skills, environmental factors, luck, and non-technical skills is explored, emphasizing the critical link between situation awareness and the diving environment. The podcast encourages post-dive debriefs to enhance understanding of problem-solving approaches and underscores the interconnected nature of situation awareness, task, and environment in diving.

In this podcast episode, the focus is on the importance of taking action and addressing issues in various environments, drawing parallels to a scenario in fire safety training. The speaker reflects on the quote, "The standard you walk past is the lowest standard you accept," emphasizing the responsibility of leaders to initiate change by not overlooking problems. The Bystander effect is explored, particularly in the diving industry, where psychological safety and lack of standards can hinder addressing issues. The podcast discusses effective strategies to counter the Bystander effect, including proactive discussions, defined team roles and standards, and the significance of briefs and debriefs in fostering a culture of learning and improvement. The episode encourages individuals to be proactive leaders, persist in initiating change, and engage with the team to maintain momentum. Additionally, we look at how change can start with one person and gain momentum with others joining in. Original blog: https://www.thehumandiver.com/blog/whose-job-is-it-to-create-change   Links: Speech from Lieutenant General David Morrison:https://youtu.be/s_TfZdIhIgg?t=156 The bystander effect video: https://youtu.be/OSsPfbup0ac Interesting leadership tips: https://www.lollydaskal.com/leadership/story-everybody-somebody-anybody-nobody/ Debrief webinar from Jenny and Mike: https://youtu.be/JTM_Lh7HtmA%C2%A0 Psychological safety blogs: https://www.thehumandiver.com/blog/team-building-psych-safety-1 https://www.thehumandiver.com/blog/team-building-psych-safety-2 https://www.thehumandiver.com/blog/team-building-psych-safety-3 https://www.thehumandiver.com/blog/team-building-psych-safety-4   Tags:  English, Gareth Lock, Leadership

In this podcast episode, Mike Mason, an instructor for The Human Diver in Australia, shares insights from his recent week-long dive training course focused on MOD 2 CCR. Emphasizing the importance of teamwork, he discusses key takeaways applicable to all divers, regardless of their specific diving interests. Mike delves into the significance of team pre-jump checks, highlighting how performing these checks as a group enhances awareness and emergency response. Gas planning and computer settings are explored, with an emphasis on independent problem-solving and the use of worst-case scenarios for safer decision-making. Mike also underscores the unique approach of physically supporting teammates during simulated problems, enhancing safety and situational awareness. The episode concludes with a recommendation for instructor Marc Crane, known for integrating Human Factors into dive training, and the value of non-technical skills in becoming a better diver. Original blog: https://www.thehumandiver.com/blog/teamwork-in-diving-what-i-learned-from-a-recent-training-course   Links: Dummies series, Leadership blog https://www.thehumandiver.com/blog/HFiD-for-dummies-teamwork   Tags:  English, Communication, Decision Making, Mike Mason, Situation Awareness, Teamwork

In this podcast episode, we explore the challenges of diver training and the limitations of a formulaic approach in preparing divers for real-world uncertainties. The discussion revolves around the difficulties of transferring tacit knowledge from experienced divers and instructors to students within the constraints of short course durations. The evolution of competence through stages—novices, advanced beginners, competent performers, proficient performers, and experts—is explored, emphasizing the importance of contextual understanding and decision-making. The episode scrutinizes the current training culture in diving, highlighting the need for frequent, reflective experiences and contextual situations for effective learning. The role of case studies, near misses, and incident reports in bridging the gap between theory and real-world application is emphasized, with a call for a just culture and psychologically safe environments for meaningful discussions and learning. The episode concludes with insights into the challenges of knowledge transfer and the significance of contextual understanding in improving diving competency. Original blog: https://www.thehumandiver.com/blog/why-diving-incident-stories-are-good-and-bad   Links: Five stages of competancy by Dreyfus https://journals.sagepub.com/doi/10.1177/0270467604264992 Flyvberg’s book on social science https://amzn.to/3ZvuXiG Essentials program https://www.thehumandiver.com/HFiD-Essentials If Only documentary https://www.thehumandiver.com/ifonly Oatmeal comic about the backfire effect https://theoatmeal.com/comics/believe The problem with transferring knowledge, Dave Snowdon https://www.researchgate.net/publication/241660493_Complex_Acts_of_Knowing_Paradox_and_Descriptive_Self-Awareness   Tags: English, Decision Making, Gareth Lock, Incident, Reporting, Just Culture, Psychological Safety

In this podcast episode, we delve into the tragic details surrounding a fatal diving accident between friends, investigating a series of factors leading to the unfortunate outcome. The incident took place outside formal dive center procedures, raising questions about the supply of compressed air by unlicensed operators and the lax recertification requirements for divers. Numerous issues emerged, such as buoyancy problems, rapid ascents, and the management of finite gas supplies. The proceedings scrutinize team protocols, gas tracking, and a lack of rescue attempts, shedding light on the complexities of mixed diving methods and decision-making under stress. The podcast highlights the intersection of errors, environmental influences, and diver fatigue, questioning the inevitability of the final outcome and implications for the criminalization of buddy system failures in the diving community.   Original blog: https://www.thehumandiver.com/blog/human-factors-analysis-of-a-maltese-diving-fatality   Links: Danish Maritime Accident Investigation Board on the grounding of the Beau Maiden: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021/   References and source materials: Summary of the judgement: https://www.divinginfo.mt/?p=1751 Judgement details (in Maltese) https://ecourts.gov.mt/onlineservices/Judgements/Details?JudgementId=0&CaseJudgementId=135422 Facebook page of the Professional Dive Schools Association of Malta: https://www.facebook.com/PDSAMalta Scuba Tech Philippines- Andy Davies: http://scubatechphilippines.com/scuba_blog/accident-analysis-gauci-2020/   Clapham Rail Crash report: https://www.jesip.org.uk/uploads/media/incident_reports_and_inquiries/Clapham%20Rail%20Crash.pdf Never Events: https://humanisticsystems.com/2016/02/27/neverzero-thinking/ Case studies from the outdoor activities sector in Australia: https://uploadsproject.org/ Criminalising human error: https://humanfactors101.com/2022/05/08/is-human-error-a-crime/ Being aware of hindsight bias doesn’t mean we won’t fall foul of it: https://www.researchgate.net/publication/10631443_Hindsight_is_not_equal_to_foresight_The_effect_of_outcome_knowledge_on_judgment_under_uncertainty The “Reasonable Man”: https://en.wikipedia.org/wiki/Reasonable_person Rodando Vought case: https://humanfactors101.com/2022/05/08/is-human-error-a-crime/ Liability of a buddy: https://www.undercurrent.org/UCnow/dive_magazine/2002/LiabilityBuddy200203.html BSAC Safe Diving Guide: https://www.bsac.com/safety/bsacs-safe-diving-guide/ BSAC Duty of Care and Welfare page: https://www.bsac.com/advice-and-support/club-support/duty-of-care-and-welfare/duty-of-care-and-welfare--club-checklist/ British Mountaineering Council Risk, Responsibility, Duty of Care and Liability Club Guidelines: https://www.thebmc.co.uk/Download.aspx?id=385 Work as Imagined vs Work as Done: https://www.youtube.com/watch?v=vtgIwHrUWVQ&list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&index=24 Professional Diving Schools Association statement: https://www.facebook.com/PDSAMalta Maltese Diving Regulations: https://legislation.mt/eli/sl/409.13/eng/pdf Everest tragedy: https://www.amazon.co.uk/Destructive-Goal-Pursuit-Everest-Disaster/dp/023000332X Loss of Situation Awareness blog: https://gue.com/blog/the-cause-of-the-accident-loss-of-situational-awareness/ The shooting down of US Blackhawks in Iraq: https://www.mindtherisk.com/literature/150-friendly-fire-the-accidental-shootdown-of-u-s-black-hawks-over-northern-iraq-by-scott-a-snook   Tags: - English, Gareth Lock, Incident Analysis, Just Culture, Psychological Safety

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

In this podcast episode, we delve into the four stages of learning, offering insights into the learning journey of a diver, from novice to expert. We begin with the first stage, unconscious incompetence, where beginners are unaware of their lack of knowledge and often rely on step-by-step instructions. The journey continues to the second stage, conscious incompetence, where novices start to realize the vast amount of knowledge and skill they have yet to acquire, often referred to as the "Mount Stupid" phase. Moving on, we explore the third stage, conscious competence, where divers begin to master skills but still need to concentrate. Finally, we reach the fourth stage, unconscious competence, where experts can execute skills almost instinctively and effortlessly. The episode emphasizes the importance of recognizing and embracing these learning stages, highlighting the role of teaching, practice, and learning from others' mistakes in the process. It also touches upon the significance of diving incident stories in the learning journey.   Original blog: https://www.thehumandiver.com/blog/the-four-stages-of-learning Links: Dunning Kruger, Unskilled and Unaware of it https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjem7i_pZOCAxUhiv0HHXTIDjUQFnoECAgQAQ&url=https%3A%2F%2Fwww.researchgate.net%2Fpublication%2F12688660_Unskilled_and_Unaware_of_It_How_Difficulties_in_Recognizing_One%2527s_Own_Incompetence_Lead_to_Inflated_Self-Assessments&usg=AOvVaw2M00VJJpL1TSHlK-6bZ-Pl&opi=89978449 Learning from others mistakes: https://www.thehumandiver.com/blog/why-diving-incident-stories-are-good-and-bad) Tags: Cognitive Biases, Decision Making, Jenny Lord

In this podcast episode, the focus is on the significance of learning from diving incidents, accidents, and near-misses, as these provide valuable lessons for safety improvement. While media attention tends to center on fatalities, the episode argues that a "Just Culture," emphasizing a psychologically-safe environment for open conversation, can promote better learning from incidents and near-misses. It addresses the prevalent tendency to blame individuals for adverse outcomes, highlighting the limitations of this approach, which doesn't consider the context or conditions that lead to these events. The episode introduces two contrasting perspectives: the Individual Blame Logic (IBL), which attributes incidents to individual choices and seeks to assign blame, and the Organisational Function Logic (OFL), which identifies systemic factors that influence outcomes and aims to improve the system. Through a case example, it illustrates how the OFL approach reveals multiple organizational and latent conditions. In conclusion, it underscores the importance of the OFL in creating a safer and more learning-oriented environment compared to the punitive IBL, which tends to conceal learning opportunities.   Original blog: https://www.thehumandiver.com/blog/who-to-blame-what-to-learn Links: A review of LiteratureIndividucal Blame vs Organisational Functional Logics in Accident Analysis. Catino, 2008: https://www.researchgate.net/publication/227822215_A_Review_of_Literature_Individual_Blame_vs_Organizational_Function_Logics_in_Accident_Analysis Tags: - English, Decision-Making, Gareth Lock, Just Culture

This podcast episode delves into the concept of a "Just Culture" in the context of diving, addressing potential confusion within the diving community. A 'Just Culture' revolves around fostering an environment of trust where individuals are encouraged to share safety-related information without fear of retribution, while also defining the boundaries between acceptable and unacceptable behavior. However, this culture can be challenging to implement effectively, as it requires post-event determinations of what's acceptable, often influenced by various biases and societal pressures. The episode explores the need to differentiate a 'Just Culture' from a 'Just Do It' culture, emphasizing the importance of sharing context-rich stories to facilitate learning from near-misses, incidents, and accidents. In the world of adventure sports like diving, where inherent risks persist, understanding cognitive biases and promoting a culture of open storytelling is crucial. The episode also touches upon the hurdles of intentionally creating cultural change within sub-communities and highlights key steps to develop a 'Just Culture' to support learning from mistakes. In essence, this discussion sheds light on the significance of learning from others' experiences to enhance safety in diving.   Original blog: https://www.thehumandiver.com/blog/a-just-culture-is-not-a-just-do-it-culture   Links: Messy World of Diving presentation: https://www.youtube.com/watch?v=vtgIwHrUWVQ&list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&index=26 Safety Clutter paper: https://research-repository.griffith.edu.au/bitstream/handle/10072/382962/Rae159320.pdf?sequence=1 A System Safety perspective of Gross Negligence: https://lup.lub.lu.se/student-papers/search/publication/9114283 Normalisation of Devience blog: https://www.thehumandiver.com/blog/normalisation-of-deviance-not-about-rule-breaking Don’t Just Focus on the Errors blog: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors Bad apples or bad day blog: https://gue.com/blog/do-bad-apples-actually-exist/ Risk or uncertainty blog: https://www.thehumandiver.com/blog/risk-or-uncertainty How to develop a Just Culture in healthcare study: https://bmjopenquality.bmj.com/content/12/1/e002049 HF for Dummies Just Culture blog: https://www.thehumandiver.com/blog/hf-in-diving-for-dummies-part-3-just-culture Is a Just Culture needed blog: https://gue.com/blog/is-a-just-culture-needed-to-support-learning-from-near-misses-and-diving-accidents/   Tags: - English, Gareth Lock, Just Culture