Counter-Errorism in Diving: Applying Human Factors to Diving

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

In this podcast episode, we explore the concept of "common sense" and how it relates to decision-making, especially in uncertain situations like diving. Often, the hindsight bias leads us to believe that situations should have been obvious, but in reality, decision-making is influenced by various factors, including previous experiences and social interactions. We delve into the mechanisms behind decision-making, highlighting the importance of shared narratives and tribal learning in developing practical wisdom rather than relying on a vague notion of common sense. The episode emphasizes the role of debriefing and reflection in improving decision-making and fostering a psychologically safe environment for learning. So, next time someone mentions "common sense," consider the complexity of human decision-making and the context in which choices are made.   Original blog: https://www.thehumandiver.com/blog/common-sense   Links: Article about naturalistic decision making: https://www.psychologytoday.com/us/blog/seeing-what-others-dont/201602/the-naturalistic-decision-making-approach AquaCORPS magazine: https://aquacorps.online/ Blog about hindsight bias: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome TED talk from Barry Schwartz about Practical Wisdom: https://www.ted.com/talks/barry_schwartz_using_our_practical_wisdom?language=en Blog about debriefing: https://www.thehumandiver.com/blog/debriefing Jenny and Mike’s DEBrIEF webinar: https://youtu.be/xzOdjNC5szU DEBrIEF guide: https://www.thehumandiver.com/debrief   Tags:  - English Decision-Making Gareth Lock Leadership Situation Awareness Teamwork

In this podcast episode, we delve into the crucial concepts of psychological safety and a Just Culture in the context of diving, teams, and organizations. These two terms, while closely related, have distinct roles in fostering learning, improvement, and safety. The episode begins with a scenario illustrating the interplay of these concepts in a diver's training journey, highlighting the impact of trust, vulnerability, and communication. Psychological safety, as defined by Professor Amy Edmondson, is explored in four stages: Inclusion Safety, Learner Safety, Contributor Safety, and Challenger Safety, each contributing to a learning-focused environment. A Just Culture, aimed at organizational improvement, is introduced as a way to analyze adverse events without resorting to blame. The episode provides insights into the proactive nature of psychological safety and the retrospective approach of a Just Culture in promoting safety and learning in diving and other domains. It emphasizes the need for open communication, understanding human error, and exploring conditions that influence behavior to enhance safety and performance.   Original blog: https://www.thehumandiver.com/blog/speaking-up-to-prevent-an-adverse-event-looking-back-to-learn   Links: Blog about near misses: https://www.thehumandiver.com/blog/were-you-lucky-or-were-you-good-2 European aviation regulations: https://www.caa.co.uk/media/sf3eiszu/fwm20160629_06_just-culture.pdf Blog about hindsight bias: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome Psychological safety toolkits by Tom Geraghty https://psychsafety.co.uk/tool-kit/ Video about Psychological safety and Just Culture: https://vimeo.com/410128892   Tags:  - English Gareth Lock Just Culture Psychological Safety

In this episode, we explore the journey of Nic Emery, a graduate of the Human Factors in Diving course, as she shares her experiences in cultivating psychological safety within her dive center, The Fifth Point. Nic emphasizes that this endeavor is a continuous process, requiring self-reflection, time, and commitment. She narrates how her team began quietly building a culture of psychological safety since 2021, influenced by the principles of Human Factors in Diving. Nic highlights the importance of open communication, vulnerability, and feedback in fostering psychological safety, both within her team and among divers. She shares a pivotal moment when they decided not to dive due to challenging conditions and how it led to a realization about the authority gradient and the need for psychological safety among customers. Nic's story showcases the gradual integration of these concepts into their dive center's culture and the steps they are taking to make it a part of their customer experience. The episode provides insights into creating an environment where individuals feel empowered to speak up and contribute to safety.   Original blog: https://www.thehumandiver.com/blog/what-are-we-pretending-not-to-know   Links: The Fifth Point diving: https://fifthpointdiving.com/ https://thehonestdiver.com/ Nic’s blog about why dive pro’s should talk about bad dives https://fifthpointdiving.com/the-dive-pro-hub/why-dive-pros-should-talk-about-bad-dives/ Display design https://drive.google.com/drive/folders/1a84tbFQcJe4RTbzxb20MWUMwJLX45gLZ?usp=sharing More blogs about psychological safety https://www.thehumandiver.com/blog?tag=psychological+safety Building a team series 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 Leadership Nic Emery Psychological Safety Teamwork

In this podcast episode, we delve into the realm of Human Factors in diving, breaking down its fundamental concept of designing systems that facilitate correct actions and deter mistakes. Human Factors in diving encompasses various aspects, including improving teaching techniques, minimizing errors in equipment use, and promoting a culture of inquiry and learning within the diving community. We explore its history in aviation and nuclear power industries, highlighting the shift from blaming individuals to understanding system limitations and human performance. The episode introduces the SHELL framework, emphasizing the interdependence of hardware, environment, software, and people in complex systems. It discusses four perspectives of Human Factors: the psychology of humans, human characteristics, factors affecting humans, and socio-technical system interaction. Additionally, we examine survey results that reveal diver perceptions of Human Factors. The episode clears misconceptions, emphasizing that Human Factors is not common sense, politeness, or just the cause of accidents. It explores the role of checklists and the challenges of implementing Human Factors in diving. Ultimately, it underscores the importance of understanding the specifics of Human Factors for effective teaching and safety improvements in diving, and the need for training agencies to integrate Human Factors into their programs for the betterment of diver safety.   Original blog: https://www.thehumandiver.com/blog/human-factors-in-diving-what-it-is-what-it-isn-t-why-you-need-to-know   Links: Insight into the background of Human Factors: https://youtu.be/iHaQjoxQlLs?si=K0CGhCzvu8pwf6wr The ‘SHELL’ framework used by the aviation community: https://skybrary.aero/articles/icao-shell-model The first of Steven Shorrock’s blogs about what Human Factors is: https://humanisticsystems.com/2017/08/11/four-kinds-of-human-factors-1-the-human-factor/ Gareth’s presentation at Rebreather Forum 4.0 https://gue.tv/programs/rebreather-forum-4?cid=3312565&permalink=5-gareth-lock-human-factors-in-diving Another series of blogs from Steven Shorrock: https://humanisticsystems.com/2019/07/10/what-human-factors-isnt-1-common-sense/ How to build a checklist (part 1 and 2) https://www.thehumandiver.com/blog/how-to-building-an-effective-checklist https://www.thehumandiver.com/blog/how-to-improve-diving-checklist-design-and-use The training courses that The Human Diver run: https://www.thehumandiver.com/training GUE tv- Human Factors for beginners: https://gue.tv/programs/human-factors-basics-for-divers Resources from RF 4.0https://bit.ly/rf4-resources   Tags:  - English Gareth Lock Human Factors