NAUI Instructor #55887 Juan Carlos Aguilar Program Evaluation, Summary, and Use in Open Water Training Human Factors Academy The-Human-Factors-Academy_4.MP4 September 20-21, 2014 Human Factors in Scuba Diving "diving fun prevention officer" Predictable Failures and the Wasted Opportunities Gareth Lock The Problems We Face #1 --organizational structure --global diversity --personal choice --aging population --risk management vs risk perception vs risk acceptance The Problems We Face #2 --lack of data or access to data --metrics of 'safety' British Hyperbaric Association treated about 350 people while only 136 reported to BSAC --culture and tradition --litigious nature of society The Problems We Face #3 --to err is human --to drift is human normalization of deviance: resetting of the baseline getting further away from what the structure is --we don't know what we don't know Dunning/Kruger effect Not Just Diving... people don't want to talk about the mistakes they've made Following the Herd how people relate in groups dive boat example: gear set up incorrectly and others don't mention it the one doing it Near Misses and Hits even with warning signs, people ignore them if you are going to do something risky, there is a need to focus the mind, body, behavior, focus, right frame of mind, dealing with anxiety Biases --hindsight bias --confirmation bias --small number bias --social desirability (positive and negative) Safety Paradox safety is typically aimed at getting numbers down to zero. the problem is, as you get safer, there is less evidence to show there is a problem. then you get to a point where you have no accidents and believe that you have something really safe. "the hardest things to prove are the obvious and a negative" Methodology #1 literature review 232 factors from 18 sources very little on organizational/supervisory issues 96 factors grouped into HFACS (human factors and classifaction structure) validate using real-world scenerios 10 scenerios (4 x OC Rec, 2 x OC Tech, 4 x CCR) quality of responses varied Methodology #2 14 SME (subject matter experts) from OC Rec to CCR and Hyperbaric Medicine 'unknown latent medical issues' (not included in methodology; autoposy, PFO,) 'violations' (no formal rules in diving unless you are teaching. rules don't exist for non-professional divers) look for distribution of 'factors' across (self-selecting) representative population Consensus of Raters --individual outlooks and biases --some consensus but not overwhelming --aligned with existing evidence on inter-rater reliability Online Survey and Results --determine distribution of factors within population --1,415 surveys started, 775 completed 10 weeks data collection period --n=332 (43%) didn't have an 'incident' --41% respondents were instructors 20% OC Tech, CCR, or CD/IT obvious bias! Type of Incident Encountered, n=443 physically OOG on a dive: 6% less than 50 bar (500 psi): 26% (unplanned) entagled/trapped: 10% uncontrolled buoyant ascent: 8% unplanned seperation: 23% hyperoxia: 1% hypoxia: 1% hypercapnia: 4% mild/severe DCS: 8% major narcosis (N2 or CO2): 6% major equipment problem: 22% (the use of the equipment properly, not a mechanical failure) total: 114% the areas with the highest proportions where action had not been take were: 61.1% (n=2,164) who had not practiced dropping weights 28.6% (n=1,012) who had dived without practicing a safety drill 19.4% (n=687) who had continued to dive when below 50 bar (500psi) 17.5% (n=620) who had not had theri own equipment serviced in the last 12 months 12.4% (n=437) who had dived beyond their maximum depth Type of Diving When Incident Occurred OC Rec: 67% OC Tech: 19% CCR: 11% OC Rec Instruction: 1% OC Tech Instruction: 1% CCR Instruction: 1% Major Factors #1 complacency: 44% overconfidence: 39% error in judgement due to lack of experience: 36% inexperience in that environment: 35% poor and/or failure to communicate: 33% unfamiliar conditions/environment: 28% haste: 26% problems involving use of equipment: 24% poor decision to continue dive: 22% misplaced motivation (goal orientated diving): 22% failure to use all resources (no using teamwork): 20% lack of awareness of buddy leading to unplanned separation: 19% normalization of deviance / external motivation factors: 19% Major Factors #2 misjudged gas consumption: 18% direct contravention of training: 18% failure of 'leadership': 18% incorrect weighting: 15% poor buoyancy control (ascent): 13% Heuristics "normally ok, no need to check. trust me": 12% "looks fine to me": 9% "not really important": 8% Behavior Changes? yes: 80% no: 20% "until you've have something exposed to you, you probably are not going to change your behavior. until something safe and scary happens, that's when it occurs." What Changed? more thorough pre-dive checking and planning: 49% increased continuation training to reinforce your existing training/knowledge/skills: 31% undertaken additional training through a recognized course: 15% do not undertake that sort of diving anymore: 4% other (n=196): 48% How to Improve Things --safety culture just culture reporting culture --honesty regarding the risks --training and standards agency team/individual --communication information source: always (n=3,540) dive club/shop (in person): 1,836 (51.86%) national diving organizations: 767 (21.67%) websites and forums: 739 (20.86%) dive club/shop (newsletter): 613 (17.31%) diving magazines: 487 (13.77%) social media: 378: (10.67%) other: 190 (5.37%) --learning to say "no" Improving the System #1 --crucial to understand "what" happened and "why" usually multiple categories involved across "system" "human error" is not an acceptable response Improving the System #2 --current process can be improved need to improve data capture and (meta-data) reporting CONCLUSION there is no one root cause -- we are part of a system we will ALL make mistakes learn from them don't hide them when you cut a corner and it goes well, don't assume it will always happen that way develop awareness, it doesn't come in a cereal box don't throw rocks at those who discuss their incidents. you might be next...