Stay ConnectedHuman factors is a critical topic within the world of SCUBA diving, scientific diving, military diving, and commercial diving. This podcast is a mixture of interviews and ‘shorts’ which are audio versions of the weekly blog from The Human Diver.
Each month we will look to have at least one interview and one case study discussion where we look at an event in detail and how human factors and non-technical skills contributed (or prevented) it from happening in the manner it did.
Copyright: © 2023 (c) The Human Diver 2023
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
In this podcast episode, Gareth explores the complexities of risk management in diving, emphasizing the hazards involved, including drowning, hypoxia, hyperoxia, entanglement, and decompression illness. The discussion challenges the traditional concept of risk, highlighting that in diving, uncertainties are managed, not risks, due to the unknown probabilities associated with events. Drawing from a real-life cave diving accident, the episode delves into cognitive biases such as availability bias, representativeness bias, and mirages, revealing how humans struggle to accurately judge risks, especially in low probability/high consequence situations. The importance of framing decisions and considering cultural effects is discussed, shedding light on the divergent perspectives within the diving community. Gareth advocates for education and systematic thinking to address biases, emphasizing the role of checklists and the unique approach of The Human Diver in managing uncertainty rather than quantifiable risk. The episode concludes by highlighting the social construction of safety and the subjective nature of an acceptable level of risk in diving.
Original Blog: https://www.thehumandiver.com/blog/risk-or-uncertainty
Links:
Plura cave diving accident: https://en.wikipedia.org/wiki/Diving_into_the_Unknown
Anchoring case study: https://youarenotsosmart.com/2010/07/27/anchoring-effect/
Dirty Dozen splash checklist: https://thedirtydozenexpeditions.com/s/Dirty-Dozen-Group-LLC-SPLASH-CHECKLIST-30-AUDITED-BY-HUMAN-FACTORS.pdf
Reference: Social Structure, Psychology, and the Estimation of Risk. Heimer, 1998: https://www.annualreviews.org/doi/10.1146/annurev.so.14.080188.002423
Tags:
English, Cognitive Biases, Decision Making, Gareth Lock
In this podcast episode, Gareth explores the nuanced meanings of terms like success, failure, good, bad, and safe within the context of a two-week workshop for developing Human Diver instructors. The workshop incorporates realistic simulations with live students from diverse backgrounds, posing challenges in team formation. The episode delves into discussions around defining success in simulations, where both positive and negative outcomes contribute to learning. Gareth shares a personal experience from the workshop, highlighting the impact of goal-oriented leadership on team dynamics and the importance of maintaining psychological safety for effective communication. The episode emphasizes the relevance of these insights to the diving community, prompting listeners to reflect on leadership styles, capacity to fail safely, emergency preparedness, and the value of non-technical skills in high-consequence environments. Ultimately, Gareth argues that being safe involves understanding context, implementing defenses, and planning to fail safely in a fallible environment.
Original Blog: https://www.thehumandiver.com/blog/success-or-failure-success-and-failure
Links:
DEBrIEF guide: https://www.thehumandiver.com/debrief
Challenger Safety: https://www.thehumandiver.com/blog/team-building-psych-safety-4
The courses we run: https://www.thehumandiver.com/hfid-level-2
Safety is not being compliant with rules: https://gue.com/blog/compliance-provides-an-illusion-of-safety-in-diving/
Tags:
English, Gareth Lock, InterLAB, Leadership, Psychological Safety, Teamwork, Training
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