In 1936, a critical event happened that changed aviation safety and saved Boeing from bankruptcy. It was the development of a checklist to help pilots remember critical steps. In 1947, researchers Fitts and Jones published a paper that said “Practically all pilots of present-day AAF aircraft, regardless of experience or skill, report that they sometimes make errors in using cockpit controls.". The point they were making was that human error was everywhere and they needed to design 'systems' to take human variability into account.

Over the coming decades, change happened but it wasn't easy. People don't like change, but when those in charge realised it could save them money, and increase their positive reputation, they started to build human factors and non-technical skills into their aircrew, engineering and ATC training programmes.

Over time, these programmes have been copied and modified to allow them to be used in healthcare, oil & gas, nuclear power, construction, veterinary practices, all with positive outcomes.

This introductory presentation will set the scene for the conference, highlighting the voyage divers have been on regarding HF in diving and what to expect over the two days of the conference.

The Just Culture process, originally introduced by James Reason in 1997, remains a popular framework helping managers to decide how to respond in cases of human error or non-conformance which contributed to an incident. However, over the years, the available evidence indicated that the original design contributed to the misapplication of the process and in some cases led to outcomes not aligned with the intent. Therefore in 2012, BP started a re-design that improved Reason's original framework towards one informed by recent studies in cognitive and social psychology, organisational justice, systems thinking and incident causation.

Bio:

Diane is the former Director, Human Performance for BP, where she delivered cultural change and safety improvement including operationalizing a “systems thinking” approach by improving the way work is set up to reduce the possibility of mistakes and make work more effective. Diane now focuses on education and advocacy.

Change can be introduced into an organisation using a combination of enforcing rules/guidelines and embedding them in the culture. In a social, dive club, there is much less scope to enforce change, even just to get the ball rolling, so trying to change the culture is the main lever that has to be used. With a diverse group of people who are primarily out to have some fun and only get together irregularly, this can present some challenges. However, the rewards of seeing behaviours change and club members doing the right thing because they believe in it and because they want to, makes the effort worthwhile. This talk will go through how our dive club has approached this, some of the wins we have had, and also some of the challenges in introducing some of the training in Human Factors and creating a Just Culture in a social dive club.

Bio:

Matthijs is an active recreational diver based in Melbourne and is the current President of the Victorian Sub-Aqua Group, one of the longest-running dive clubs in the world.

A strong prevention bias in safety thinking doesn’t offer a robust understanding of the complexity of high consequence events. Despite the best risk assessments, procedures, and people, we simply cannot prevent all incidents. We must instead balance prevention efforts with capacity to respond and recover when things go badly. But how do we apply this in our diving?

This session offers a simple visual model (along with a backstory) to stimulate discussion and promote learning, shared understanding and a language of safety differently, in the context of the buddy system in Scientific Diving. The model is an adaptation of the bowtie model – but with a twist.

On one side of the traditional bowtie model, prevention efforts deter threats, while on the other side capacity to respond to events reduces impact. The centre represents operational activity and an event moment. This is also the moment when people recognize anomaly and make sense of the information, learn in the moment, and innovate a change to the system.

In our adaptation, the bowtie is depicted inside a sphere of influence representing the margin of manoeuvre. Positive influences create an outward force to maintain a buoyant sphere. Negative influences put pressure on the system, reduce its size, robustness and even collapse it. An unbalanced bowtie can also collapse the system.

Then we shift the model from bowtie to propeller, making it dynamic, and demonstrating how learning creates a feedback loop to improve the entire system- including preventive, operational and response/recovery components.

Bio:

Vallorie Hodges is the University Diving Officer and Safety & Wellbeing Advisor at the University of Tasmania with a passion for human factors and safety differently.

Dive Masters deal with different divers all the time. These divers come from different cultural backgrounds, different training organisations and have different levels of ability.

A qualified Dive Master will routinely take a diverse group of people diving in good conditions at familiar dive sites without suffering serious mishaps. However, there are often little things that happen that weren't part of the plan that gets ignored or forgotten and are rarely discussed after the dive.

When incidents do occur, it is often as a result of lots of these little mishaps coming together at the same time. By discussing real-life diving incidents,

Mike will look at several different examples of Human Factors where Dive Masters were involved and what can be learned to try and avoid similar incidents happening in the future. The main aim is to provide some specific advice on how Dive Masters can apply Human Factors to make their diving and that of their fellow divers safer, more productive and more enjoyable.

Bio:

Mike is an experienced military pilot and flying instructor in his day job and works as a Dive Master at weekends. He is also training to become an instructor for The Human Diver and is always striving to improve diving by applying Human Factors.

In December 2018 a young and fit commercial diver suffered near-fatal injuries arising from a poorly managed series of dives using ‘no stop/no decompression’ tables.

“Deep, dark and dangerous” and “How can this be of relevance to me?” I’m sure you are thinking? This was a surface supplied commercial dive after all.

This is of direct relevance to you because it was the result of a series of 5 ‘no stop’ dives conducted over a number of days and all to circa 20 metres water depth and all conducted using air as the breathing gas. Just like your own holiday and expedition dives I’m sure. OK, he was working hard but then again, we all encounter hard work on dives too, often due to current and having to fin hard. His daily dives were run according to USN 7 tables for repetitive diving.

The dives did, however, push the defined limits and during his last dive, he experienced what can only be described as a more-than-usual rapid ascent to the surface. The rapid onset of what was subsequently identified as a Type II DCI, vestibular bend was then compounded by what can only be described as poor emergency management. It took 6 hours to get him into a chamber for recompression and this involved a helicopter flight to a neighbouring island. Incredibly there was a chamber 4 minutes away from the site of the incident but the supervisory team on-site decided not to use it.

There is more, much more and this presentation provides many learning points for us all, no matter what type of diving we do. Human physiology is common to us all, as are the laws of physics. Lewis wants to share what happened to him so that others may learn and avoid what happened to him. He wants us to benefit from his near-death and certainly life-changing diving incident.

Bio:

I’ve been a diver since the 1970’s and freely admit to a particular passion for wrecks but actually my real passion is diving, diving of any form.

When a dive incident happens, focus is often put on external factors and in serious accidents often scarce and misleading news is published by specialised as well as general media.

With an average of 5500 emergency calls received every year worldwide - ranging from trivial to deadly - the DAN team has been collecting a wealth of data in its 40-year-long history.

The presentation aims at shedding more light on what really happens when the alarm centre is notified of an emergency, the procedures followed to promptly respond, the service providers involved, and how all this is coordinated to improve the diver’s conditions and avoid further damage.

Some real case scenarios will be provided, to add a more practical, concrete perspective on the subject.

The data collected and the experience gained also allow us to analyse what are the most recurring incidents and why they happen, providing interesting considerations about human factors as well.

Short Bio:

Laura is the Executive Vice President of DAN (Divers Alert Network) Europe, and a scuba diving instructor and a passionate technical and cave diver. Her mission is to help promote a culture of safety within the diving industry, continuing what the organisation that now she leads has been doing for over 40 years now.

If only we could prevent every bad thing by capturing it in a rule. But that’s not possible. Yet, we try to do just that. Humans are practical creatures and we will always look for the most efficient way to get the desired results. Even if this means not following the rules. “It’s the result that matters!”, right?

Bio:

Bart den Ouden is a TDI Advanced Mixed Gas (OC & CC) Instructor Trainer, PADI Course Director and Instructor Trainer for Disabled Divers International (DDI), DAN Europe & Emergency First Response Corp. (EFR). He is also a security professional, an examiner for the Dutch Security Exam Board and an instructor for The Human Diver and he lives in Rotterdam, Netherlands.

Human beings have evolved to be able to make rapid decisions with incomplete information using heuristics which rely on experiential learned rules and cognitive biases. With examples from healthcare and other sectors we will explore the benefits and pitfalls of heuristic decision making and strategies for improving decision making in diving.

Bio:

Tristan Cope is Executive Medical Director and a consultant in Critical Care Medicine at Liverpool University Hospitals. He is also Lead Clinician at the North West Recompression Unit on the Wirral.

As human activities become increasingly complex, operational failure due to omitted critical steps becomes more and more likely. In many fields, this can result in serious injury or death. Relying on expertise or experience alone introduces a failure mode related to the wide range of conditions that can negatively impact the operation of the human brain. Anger, sickness, distraction, and other such states can make mnemonic devices and well rehearsed routines fail, with catastrophic results. A physical, printed checklist, when combined with appropriate procedures for following such a list acts as a line of defense against such failure. These lists have been successfully implemented in a number of high-stakes fields, such as diving, surgery and aviation. This talk will review their use and make recommendations for implementation by scuba divers to enhance safety.

Bio: 

I am a pediatric otolaryngologist in New York City and a technical rebreather diver. I have served as the president and dive chair of the New York City Sea Gypsies, and I am a medical moderator on scubaboard.com. I am also an avid underwater photographer and videographer, and currently the co-director of the New York Underwater Photographic Society.

We now have multiple decades of CCR operation by sport divers. Over that time, diving knowledge has improved, manufacturing has improved, training has improved, data recording has improved and the factors contributing to incidents has shifted accordingly. This shift has reduced some factors, leaving human factors in a more prominent role. This presentation explores how human factors are addressed in safety testing and outlines some scenarios where this approach could be updated.

Bio:

Tim started diving in 1990 while studying Marine Biology and Oceanography, becoming a BSAC Advanced Diver, followed by MSc and HSE Part IV qualifications. He is now heavily involved in the RedBare CCR development as well as managing the Vobster Quay dive site.

Most technical dive training focuses on equipment management and technical skills such as buoyancy control. Little to no time is given over to non-technical skills such as decision making and communication. Yet, these factors can play a critical role in how a dive team performs under pressure. It is possible to thread an awareness of human factors through technical training from day one. I have been doing this for several years and I have developed and will share some useful strategies that I have found successful.

Bio:

Guy Shockey is a full time Global Underwater Explorers Instructor Evaluator who teaches all of GUE’s technical diving courses including both OC and CCR. He is a former military officer with experience in military aviation and has a graduate degree in political science. He is also one of the first Human Diver instructors and he is passionate about including Human Factor’s training in all his technical dive training.

DAN has collected diving incidents and fatalities for almost four decades. A number of the voluntarily reported incidents have been published in the Annual Diving Report or were featured on the DAN.org website or in Alert Diver Magazine. Since 2012, the DAN Diving Incident Reporting System (DIRS) is an online application and has collected hundreds of incidents and experience reports that divers were kind enough to share. The incidents cover everything from pre-planning of a dive, to equipment failures at the surface or in the water, to adverse situations during a dive that triggered an undesirable outcome. Divers share these experiences about these events, including mistakes that were made, injuries that occurred and possible contributing factors with DAN in the hope that others can learn from their stories. DIRS has recently undergone some changes and has incorporated more detailed questions pertaining to Human Factors, which will be highlighted in this talk. You will learn how the DAN team reviews the submitted incidents and what you can expect from us when sharing your experiences with us.

Bio:

Frauke Tillmans is the Research Director at Divers Alert Network. With a PhD in human biology and extensive experience in different areas of diving, including recreational, technical, cave, scientific, and public safety, she has brought some new perspectives into the injury monitoring initiatives at DAN.

Accidents happen, no matter how hard we try to keep divers safe, because people make mistakes.  For example, in a review of 1,000 recreational diving mishaps performed in Australasia, 87 percent were found to be caused by human error; while inexperience and insufficient training accounted for 14 percent and eight percent, respectively, of the contributing factors to mishaps.  In other words, the vast majority of accidents happen because people make a mistake, with a smaller number caused by people getting in over their heads.  For this reason, when a diving accident occurs, an investigation of some type usually follows.  It is important for you to understand the process as the investigation moves forward.  This presentation describes, in detail, what happens after the accident. 

Bio: 

David Concannon is an attorney with more than 40 years of experience as a scuba diver and 30 years as a trial lawyer in courtrooms around the United States.  Through his law firm, Concannon & Charles, David represents a myriad of clients in the diving industry and he is an expert on the legal issues associated with scuba diving.

From the Ground Up covers the preventable events that led to a diver decompression injury, the ensuing regulatory investigation that caused the team to be shut down, and the eventual rebuilding process to get back in good standing.

Bio:

Tim Andro is the owner and lead SDI/ERDI instructor for Northeast Public Safety Divers, a premiere public safety dive training center for the northeast U.S. He has almost 20 years of recreational and technical dive experience, including Advanced Trimix and Closed-Circuit Rebreather, and has logged over 3,000 dives. He has also been a firefighter for 22 years, 10 of those as a public safety diver, and is the current Dive Coordinator for Mahwah Fire & Rescue Co #1, and the current Vice President of the North Jersey Regional SCUBA Task Force.

Panic is a physiological and psychological state that can occur when a person is under stress. It involves extreme levels of emotional arousal (high or low) and associated changes in thinking, information processing, and attention. In this state, a person is not able to think clearly or consciously control their actions. Behaviour is instinctive, and the brain drives processes for immediate survival; leading to actions which can be effective on land, but are potentially fatal underwater. Entering a state of panic is always possible, even for well-equipped, experienced divers, but it is not inevitable.

Bio: 

Dr Laura Walton is a Clinical Psychologist, specialising in Diving Psychology; and a Scuba Diving Instructor. Her perspectives on stress, anxiety and panic in diving arise from knowledge of psychological theory, clinical practise and informal observation of diver behaviour.