Counter-Errorism in Diving: Applying Human Factors to Diving

In this podcast episode, Gareth reflects on the challenges of learning from near-misses, particularly in the context of recent tragic events involving the loss of the Titan submersible. The episode explores the biases that hinder our ability to analyze and learn from incidents, emphasizing the complexities of socio-technical systems and the difficulties in replicating conditions for learning. Drawing parallels with diving, Gareth discusses the dynamic nature of risks, the fallacy of binary safety assessments, and the importance of recognizing uncertainties. The episode delves into cognitive biases, heuristics, and psychological factors influencing decision-making, shedding light on the sunk cost fallacy, prospect theory, and the local rationality principle. It advocates for a culture of learning, critical debriefs, and the application of human factors principles in diving. Ultimately, the episode encourages listeners to approach incidents with curiosity, suspend judgment, and seek to understand the local rationality of those involved. The tragic loss of the Titan submersible serves as a poignant reminder of the imperative to learn and improve safety in complex systems. The episode concludes by honoring the lives lost in the incident. Original blog: https://www.thehumandiver.com/blog/its-obvious-why-it-happened   Links: How Near-Misses Influence Decision Making Under Risk: A Missed Opportunity for Learning: https://pubsonline.informs.org/doi/10.1287/mnsc.1080.0869 If we want to learn, notice the conditions, not the outcomes: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors AccipMap: https://linkinghub.elsevier.com/retrieve/pii/S000368701730100X DMAIB report: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021/ Implications for hindsight bias: https://www.semanticscholar.org/paper/Perspectives-on-Human-Error%3A-Hindsight-Biases-and-Woods/d913cdeae4e2782881a52e635e06c208b0796aed If the adverse event occurs in an uncertain or unusual environment, then we are more likely to judge it more harshly: http://journals.sagepub.com/doi/10.1177/0146167292181012 Five principles behind High-Reliability Organisations (HRO): https://www.high-reliability.org/faqs?_gl=1*j0ylqo*_ga*NDkyNjExMzA3LjE2ODc2Nzc2NTI.*_ga_TM3DC1EMKK*MTY4NzY3NzY1MS4xLjEuMTY4NzY3OTI2OC4wLjAuMA.. Prospecive hindsight/Pre-mortems: https://www.thehumandiver.com/blog/how-to-help-correct-the-biases-which-lead-to-poor-decision-making Red Team Thinking: https://www.redteamthinking.com/ Guy’s blog, Is the Juice Worth the Squeeze?: https://www.thehumandiver.com/blog/is-the-juice-worth-the-squeeze Doc Deep’s final dive: https://gue.com/blog/i-trained-doc-deep/ Single and Double Loop learning: https://hbr.org/1977/09/double-loop-learning-in-organizations Columbia Accident Investigaion Board: https://govinfo.library.unt.edu/caib/news/report/pdf/vol1/chapters/chapter8.pdf New ways to learn from the Challenger disaster: https://dx.doi.org/10.1109/aero.2015.7118898 Drop your Tools: http://www.jstor.org/stable/2393722 Availability, Representativeness & Adjustment and Anchoring: https://www2.psych.ubc.ca/~schaller/Psyc590Readings/TverskyKahneman1974.pdf Trieste record breaking dive: https://www.usni.org/magazines/proceedings/2020/january/first-deepest-dive Resources from RF4 presentation: https://bit.ly/rf4-resources Psychological safety, Tom Geraghty’s site: https://psychsafety.co.uk/ Normal Accidents: https://en.wikipedia.org/wiki/Normal_Accidents Tags:  English, Decision Making, Gareth Lock, Human Factors, Incident Investigation

In this podcast episode, Gareth delves into the concept of near-misses in diving, exploring the two categories: those that "could happen" and those that "almost happened." The distinction lies in background risks versus perceived risks influenced by cognitive biases. The episode draws parallels with real-world examples, such as the normalization of risks in the space shuttle Columbia tragedy. Three dive scenarios are presented, examining the outcomes and whether the participants were lucky or skilled. The discussion emphasizes the impact of successful near-misses on risk perception, leading to potential complacency. The episode concludes with insights into mitigating these issues, promoting counterfactual thinking, and stressing the importance of effective debriefs to enhance learning from near-misses. The audience is encouraged to reflect on successful outcomes and consider whether they were lucky or good in order to improve diving practices. Original blog: https://www.thehumandiver.com/blog/were-you-lucky-or-were-you-good-2   Links: Normalisation of Deviance blog: https://www.thehumandiver.com/blog/normalisation-of-deviance-not-about-rule-breaking Debrief model: https://www.thehumandiver.com/debrief How Near-Misses Influence Decision Making Under Risk: A Missed Opportunity for Learning. Dillon & Tinsley, 2008: https://pubsonline.informs.org/doi/10.1287/mnsc.1080.0869   Tags:  English, Decision Making, Gareth Lock, Normalisation of Deviance, Risk Management

In this podcast episode, Gareth recounts the experience of an experienced cave diver during what was intended to be a routine sidemount dive. Despite their expertise and previous successful dives, this particular excursion took an unexpected turn, prompting reflection on why certain factors may not be apparent in the moment but become evident in hindsight. The episode explores the physiological and cognitive aspects affecting diver performance, touching on concepts like working memory, task load, and background cognitive loading. Analogies such as juggling and buckets of water are used to illustrate the limitations of cognitive capacity. The impact of being submerged on cognitive performance is discussed, emphasizing the need for awareness and adaptation during underwater activities. The episode concludes with insights into the narcotic effects of gases, particularly nitrogen and carbon dioxide, and examines the specific context that contributed to the diver's challenges. The importance of resilience in the face of errors is highlighted, encouraging listeners to understand the local rationality of those involved in adverse events and emphasizing the value of learning from near misses. Original blog:  https://www.thehumandiver.com/blog/please-sir-my-brain-is-full   Links: Carl Spencer’s last dive: https://www.sidetracked.com/the-siren-song-of-the-britannic/ Dalecki et Al, 2012: https://link.springer.com/article/10.1007/s00221-012-2999-6 Oxygen narcosis research: https://pubmed.ncbi.nlm.nih.gov/35859332/   Tags: English, Cognitive Biases, Decision Making, Gareth Lock, Incident Analysis

In this podcast episode, Gareth shares insights gained from conversations with survivors of the recent Carlton Queen liveaboard incident off the coast of Egypt. The survivors recounted harrowing experiences during the ship's sinking and discussed conditions that seemed "odd" in hindsight. The episode delves into the challenge of recognizing latent factors contributing to accidents before they occur and emphasizes the importance of understanding what 'normal' looks like in various situations. Drawing on the survivors' perspectives, Gareth explores the powerful effects of hindsight bias, providing practical tips for reducing its impact when analyzing events and learning from them. The episode concludes with a call for active reflection and the use of tools like DEBrIEF to uncover error-producing conditions and improve safety. Original blog: https://www.thehumandiver.com/blog/would-you-do-the-same-thing   Links: Looking for patterns: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome Error producing conditions: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors Debrief guide: https://www.thehumandiver.com/debrief   Tags: English, Decision Making, Gareth Lock, Hindsight Bias

In this podcast episode, Gareth reflects on the power of assumptions in everyday life, using examples ranging from a humorous cycling sign to more serious incidents in diving. The discussion explores how assumptions, while essential for navigating the complexity of daily activities, can sometimes lead to oversights and mistakes. Drawing parallels with diving scenarios, the episode emphasizes the critical need to validate certain assumptions, especially those related to safety in the underwater environment. Gareth shares insights into the recent incident involving the Carlton Queen liveaboard, highlighting the individual and systemic failures that contributed to the event. The episode concludes by advocating for a shift from a punitive approach to a restorative one in learning from mistakes and fostering a culture of safety in diving. Original blog: https://www.thehumandiver.com/blog/assumptions-a-paradox   Links: Cognitive bias infographic: https://medium.com/thinking-is-hard/4-conundrums-of-intelligence-2ab78d90740f Buster Benson’s original blog about cognitive bias: https://betterhumans.pub/cognitive-bias-cheat-sheet-55a472476b18 Debrief model: https://www.thehumandiver.com/debrief   Tags:  English, Cognitive Biases, decision Making, Gareth Lock, Just Culture

In this podcast episode, the focus is on how we interpret and learn from incidents in diving. Using the analogy of a vase breaking, the episode explores how the language we use to describe events can influence our understanding. It presents two diver scenarios, emphasizing the importance of context in shaping behavior and decision-making. The podcast delves into research showing biases in incident reports, where a linear-cause-and-effect narrative leads to individual blame. It stresses the need for context-rich narratives for a more comprehensive understanding of incidents. The episode discusses cultural influences on diving safety protocols and calls for a shift from an individual-blame approach to a systemic understanding of failures. It concludes with an announcement of "Learning from Unintended Outcomes" course and upcoming comprehensive guide on moving from blame to learning in diving incidents using a human factors and system-learning approach. Original blog: https://www.thehumandiver.com/blog/watch-what-you-say   Links: The role of agency in discussing dive incidents: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/ 2018 Research aboout linear reports: https://www.mdpi.com/2313-576X/4/4/46 2023 research about experienced vs inexperienced analysis: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1144921/full Work as imagined vs work as done: https://www.youtube.com/watch?v=vtgIwHrUWVQ&list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&index=26 Two contrasting views of the South Korea ferry accident: https://vimeo.com/122851457 Moving from an individual blame focused approach to one that looks at the wider system: https://www.researchgate.net/publication/227822215_A_Review_of_Literature_Individual_Blame_vs_Organizational_Function_Logics_in_Accident_Analysis Learning from Unintended Outcomes course: https://www.thehumandiver.com/lfuo   Tags:  English, Communication, Gareth Lock, Incident Investigation, Just Culture

In this podcast episode, the discussion revolves around risk management in diving, sparked by an incident in a remote location. The episode explores fundamental principles applicable to all diving scenarios. It begins by emphasizing the inherent hazards in diving and the potential fatal outcomes associated with various risks. The "bow-tie model" is introduced to illustrate preventive measures, controls, and mitigations. The episode further delves into the Four Ts of risk management—Treat, Transfer, Tolerate, and Terminate—and explains their relevance to diving, considering factors like training, equipment, and environmental conditions. The inherent and irreducible risk in diving is acknowledged, with a focus on the delicate balance between risk and reward, highlighting the trade-offs involved in decision-making. The podcast concludes with a scenario-based exploration of risk management strategies in a remote diving expedition, addressing the complexities and interdependencies of the 4Ts. The episode encourages listeners to consider these principles when assessing risk in their diving experiences and emphasizes the importance of a multi-layered approach to achieve a tolerable level of risk. Original blog: https://www.thehumandiver.com/blog/risk-management-in-diving   Links: The confusing concept of inherent risk: https://drive.google.com/file/d/1GFVM8QrNv0zfevkiGBX38SC-MJWYNdco/view?usp=sharing Human Diver blog about risk or uncertainty: https://www.thehumandiver.com/blog/risk-or-uncertainty Dirty Dozen checklist: https://thedirtydozenexpeditions.com/s/Dirty-Dozen-Group-LLC-SPLASH-CHECKLIST-30-AUDITED-BY-HUMAN-FACTORS.pdf Pschosocial risks: https://www.hse.gov.uk/msd/mac/psychosocial.htm More Human Diver blogs: https://www.thehumandiver.com/blog?tag=cognitive+biases Blog about hindsight bias: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome   Tags:  English, Checklists, Cognitive Biases, Decision Making, Gareth Lock, Risk Management

This podcast episode explores the critical importance of designing checklists for rebreather and general diving operations, drawing parallels with aviation practices. The episode delves into the 'Challenge and Response' checklist method widely used in aviation, emphasizing its role in enhancing safety, systematic verification, and crew coordination. The discussion addresses reasons for deviations from checks, including distractions, individualism, complacency, and frustration, with insights from aviation incidents. Solutions to these challenges are presented, advocating for optimal checklist initiation, managing interruptions, and thoughtful checklist design based on human factors principles. The episode concludes by underlining the need for checklists as integral tools in diving safety, urging consistent usage within a robust social system to minimize deviations and enhance overall operational safety. Original Blog: https://www.thehumandiver.com/blog/how-to-improve-diving-checklist-design-and-use   Links: Original checklist blog, part one: https://www.thehumandiver.com/blog/how-to-building-an-effective-checklist Ross. Human Factors Issues of the Aircraft Checklist, 2004: https://commons.erau.edu/cgi/viewcontent.cgi?article=1553&context=jaaer Degani, Asaf; Wiener, Earl L. (1990) Human Factors of Fight-Deck Checklists: The Normal Checklist. Contract No. NCC2-377. A report prepared for Ames Research Center:​​ https://ntrs.nasa.gov/citations/19910017830 Degani, A. and Wiener, E. L. (1994). On the Design of Flight-Deck Procedures. (NASA Contractor Report 177642). Moffett Field, CA: NASA-Ames Research Center: https://ntrs.nasa.gov/citations/19940029437   Tags: English, Checklists, Decision Making, Gareth Lock, Non-Technical Skills, Situation Awareness

This podcast episode explores the crucial role of checklists in enhancing safety and standardizing procedures in various fields, with a focus on diving. Delving into the complexities of checklist design and execution, the discussion emphasizes the importance of considering human factors, operational conditions, and the social environment. While checklists play a vital role in promoting mutual monitoring and coordination during high workload periods in dive operations, the episode highlights the need for balance in standardization, length, typography, and phraseology. The podcast underscores the significance of addressing cognitive limitations and potential error-producing conditions, advocating for the thoughtful design of checklists based on human factors principles. The episode concludes by stressing that checklists are not a one-size-fits-all solution; they must be integrated into a team with a shared commitment to adherence and accountability for effective risk management in diving operations. Original Blog: https://www.thehumandiver.com/blog/how-to-building-an-effective-checklist   Links: World Health Organisations Surgical Safety Checklist: https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources Part 2 original blog: https://www.thehumandiver.com/blog/how-to-improve-diving-checklist-design-and-use Degani, Asaf; Wiener, Earl L. Human Factors of Fight-Deck Checklists: The Normal Checklist. Contract No. NCC2-377. A report prepared for Ames Research Center. May 1990: https://ntrs.nasa.gov/citations/19910017830 Degani, Asaf. On the Typography of Flight-Deck Documentation. Contract No. NCC2-327. A report prepared for NASA. December 1992: https://ntrs.nasa.gov/citations/19930010781 Burian, Barbara. “Design Guidance for Emergency and Abnormal Checklists in Aviation.” In Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting. 2006: https://www.researchgate.net/publication/253033092_Design_Guidance_for_Emergency_and_Abnormal_Checklists_in_Aviation   Tags:  English, Checklists, Decision Making, Gareth Lock

In this podcast episode, Gareth delves into the nuanced concept of safety in diving, challenging the perception of what constitutes a "safe" dive. Examining different dive scenarios, from reef dives to wreck penetrations and cave dives, the episode explores the subjective nature of acceptable risk levels based on individual training, skills, and experience. Drawing on a healthcare safety framework, the discussion categorizes safety approaches into "Ultra Adaptive," "High Reliability," and "Ultra Safe," questioning where the diving industry aligns in terms of risk management. The lack of precise data on diving failures and fatalities is highlighted, challenging the commonly cited failure rate. The episode encourages listeners to reconsider their understanding of a "safe" dive, emphasizing the importance of regular emergency and rescue plan validation, skill practice, and reflective debriefs to foster a true sense of safety in diving. Gareth prompts listeners to contemplate their personally constructed views of safety and the potential challenges when these views differ within a dive team, stressing the need for a psychologically-safe environment for effective risk management discussions. Original Blog: https://www.thehumandiver.com/blog/what-does-safe-mean   Links: Framework of contrasting approaches to safety: https://dx.doi.org/10.1007/978-3-319-25559-0   Tags: English, Decision Making, Gareth Lock, Risk, Risk Management, Safety Culture