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