Culture. Isn’t just something that grows in the lab (or kitchen)

Culture. Isnt just something that grows in the lab (or kitchen)...

Improving Diving Safety Through Improved Reporting and a Just Culture

Gareth Lock E: [email protected] M: 07966 483832

Scope Risk Cultures What is an Incident? Reporting, why should I? Case Studies Reporting Opportunities DISMS Conclusions

Introduction

Full time RAF Officer (ex C-130 aircrew)

Adv Trimix Diver Studying for PhD

Cranfield

Cognitas in 2010 DISMS launched Apr 2012

Risk, What is It?

Risk, What is It? What is risk?


Probability x Impact


Probability x Impact Acceptable level based on

Experience, Attitude, Training and Culture...


Probability x Impact Acceptable level based on

Experience, Attitude, Training and Culture...

Relative

Risk, What is It?

Risk, What is It?

Diving is risky What is risk?

Risk, What is It?

Diving is risky Baselines are required

What is risk?

Risk, What is It?

Diving is risky Baselines are required Understand the risks

What is risk?

Risk, What is It?


Educate but dont scare

What is risk?

Risk, What is It?


Educate but dont scare Mitigate and reduce them

What is risk?

Risk, What is It?


Educate but dont scare Mitigate and reduce them

To improve safety, not primarily reduce litigation

What is risk?

Risk, What is It?

Incident

Risk, What is It?

zIncident

Safe Limit for Recreational

Diving

Safe Limit for Technical!

Diving

Safety Margin

Risk, What is It?

zIncident


Diving


Diving

Human Error!(Active/Latent)

Risk, What is It?

zResources

Incident


Diving


Diving


Risk, What is It?

zResources

IncidentBad Luck!


Diving


Diving


Risk, What is It?

zResources

IncidentBad Luck!


Diving


Diving


Training

Risk, What is It?

zResources

IncidentBad Luck!


Diving


Diving


Training

Feedback

Risk, What is It?

zResources

IncidentBad Luck!


Diving


Diving


Training

ReportingFeedback

Cultures

Cultures What are they?


Culture can be described as the shared values and beliefs within an organization which create

behavioural norms (Shaw and Blewitt, 1996)


Common Beliefs Common Goals Common Behaviours

Cultures

Cultures Safety Culture

Cultures Safety Culture

Reporting Culture Just Culture Informed Culture Learning Culture Flexible Culture

Safety Culture

Reporting Culture

Reporting Culture Linked to Just Culture Survey initiated as part of PhD

Reporting Culture Survey

Reporting Culture Survey

Percentage of Divers Had Incidents?

Types of Incidents Knowledge of the BSAC

system

Reasons for not reporting DCI Occur vs Report

Survey: OC/Tech/CCR/All

Rec,%72.41%%Tech,%38.07%%

CCR,%8.28%%All,%10.90%%

OC#Rec,#OC#Tech,#CCR#or#All#

Rec%

Tech%

CCR%

All%

The diving profile of all 725 UK respondents

Survey: Age

0.0%$

4.6%$

7.2%$

16.0%$

18.1%$19.8%$

14.0%$

11.5%$

8.6%$

0.3%$0.0%$

5.0%$

10.0%$

15.0%$

20.0%$

25.0%$

Under$16$

16325

$

26330

$

31335

$

36340

$

41345

$

46350

$

51355

$55+$

Not$Listed$

Tech/CCR:)Age)of)Respondents)

Tech/CCR:$Age$of$Respondents$

Nearly 54% respondents are over 40 yrs age, 57% within total community, 59% Rec only

Survey: Had An Incident?

Yes,%80%%

No,%17%%

No%Answer,%2%%

Ever%Had%An%Incident%Yes/No?%All%Divers%OOA,%Separa;on>Solo%Ascent,%UBA,%DCI%

Yes%

No%

No%Answer%

Survey: Knowledge of BSAC Reporting (Tech & CCR)

No#ANSWER,#2.3%#

Know#Nothing,#16.9%#

Heard#About#it,#23.2%#

Occasional,#30.9%#

Every#Year,#18.8%#

Every#Year/Report,#6.3%#

Tech%(OC%&%CCR).%Non0BSAC.%%Knowledge%of%BSAC%Incident%Repor?ng%System%

No#ANSWER#

Know#Nothing#

Heard#About#it#

Occasional#

Every#Year#

Every#Year/Report#

Survey: Knowledge of BSAC Reporting (Rec)

No#ANSWER,#1.3%#

Know#Nothing,#37.6%#

Heard#About#it,#33.8%#

Occasional,#18.5%#

Every#Year,#8.9%# Every#Year/Report,#0.0%#

Rec$Only.$Non,BSAC.$$Knowledge$of$Incident$Repor;ng$System$

No#ANSWER#

Know#Nothing#

Heard#About#it#

Occasional#

Every#Year#

Every#Year/Report#

Survey: Reasons for Not Reporting - All Divers

27% Not BSAC Member. 34% Trivial/Not Serious

Didn't'Know'About'BSAC'Annual'

Incident'Report'11%'

Not'BSAC'Member'20%'

Didn't'Know'How'To/Should'Do'5%'

Apathy/Laziness'5%'

Resolved'before/aKer'Surfacing'4%'

Unlikely'to'Contribute'to'Learning/Trivia/Not'Serious'

23%'

Report'to'PADI/SAA/DISMS/Other'Agency'

3%'

Lack'of'Trust/Belief'in'Current'System'

5%'

Lack'of'Clarity'of''Incident''9%'

Overseas'Incident'5%'

Completed'by'Someone'else'4%'

Lack'of'Time/Forgot'4%'

Embarrassment/Personal'Feelings'

1%' Incident'Happened'to'Someone'Else'

1%'

Reasons'for'Not'Repor-ng'(n=419)'

DCI vs Reporting

2010 BSAC Figures: 105 2010 BHA Chamber Recompressions ~350 DDRC Study 2002 - ~45% self diagnosed

DCI didnt reported to chamber

2012 Reporting Survey Tech Only (#349), DCI Yes - ~25% All Instructors, DCI, not chamber - ~10%

Reporting Culture

Reporting Culture Improvements are

needed


needed Guidelines on what is an

Incident

Independence may improve uptake

Easy to submit report Useful outputs Promotion of Reporting


needed

Govaarts C. EAM 2/GUI 6 - Establishment of Just Culture Principles in ATM Safety Data Reporting and Assessment. Safety Regulation Unit, EUROCONTROL; 2006.

Guidelines on what is an Incident

Independence may improve uptake

Easy to submit report Useful outputs Promotion of Reporting

Just Culture

Just Culture Not no blame

Just Culture Not no blame The environment to talk about or

report an incident without fear of retribution (professional/peer)

Consoling the human error Coaching the at-risk behaviour Punishing the reckless behaviour

Not no blame

Just Culture Not no blame The environment to talk about or

report an incident without fear of retribution (professional/peer)

Consoling the human error Coaching the at-risk behaviour Punishing the reckless behaviour

Who draws the line...?

Not no blame

What is an Incident?

What is an Incident?National Research Council defines a safety incident as an event that, under slightly different circumstances, could have been an accident.National Research Council, Assembly of Engineering, Committee on Flight Airworthiness Certification Procedures. Improving aircraft safety: FAA certification of commercial passenger aircraft. Washington, DC: National Academy of Sciences, 1980.

What is an Incident?National Research Council defines a safety incident as an event that, under slightly different circumstances, could have been an accident.National Research Council, Assembly of Engineering, Committee on Flight Airworthiness Certification Procedures. Improving aircraft safety: FAA certification of commercial passenger aircraft. Washington, DC: National Academy of Sciences, 1980.

We defined a near miss as any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome. Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ 2000, Mar 18;320(7237):759-63.

What is an Incident? Unplanned separation at depth, solo ascent

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox CO2 hit

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox CO2 hit DCI end in paralysis

What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox CO2 hit DCI end in paralysis Fatality

What is an Incident? 10% Lack of Clarity

More guidance required

What is an Incident? 10% Lack of Clarity

More guidance required 34% Trivial/Not Serious/Not

Contribute to Learning

Why do we still make same mistakes?

Not perceived as relevant to my deep gas diving. - referring to BSAC AIR

Case Study One MCCR Shutdown

Image from www.kissrebreathers.com


Experienced Trimix Instructor, Relatively New CCR Diver




Forgetting O2 shutdown post dive





Shutdown O2 progressed from dekitting to on lift






Shutdown in water waiting for previous diver/lift






Shutdown in water waiting for previous diver/lift

PPO2 0.07 on lift Image from www.kissrebreathers.com


Reported: Diver shutdown O2 in water. Broke rules.



Reported: Diver shutdown O2 in water. Broke rules.

Not one reason for incident, back story possible to understand WHY


Case Study Two CCR Narcosis


Experienced MOD 3 level CCR Diver



Stressful previous days



Stressful previous days Issues on descent, carried

on despite ascending to clear





CO2/N2 Narcosis and bailed out, then problems started!





CO2/N2 Narcosis and bailed out, then problems started!

Fortunately resolved at 21m on OC bailout after 20mins


Likely Reported: Potential narcosis leading to bailout


Likely Reported: Potential narcosis leading to bailout

Not one reason. Many opportunities to stop incident developing. Full story required to understand WHY

Reporting, Why Should I?

Reporting, Why Should I? What is the Risk?

Reporting, Why Should I? What is the Risk? How Big Is the Problem?

Reporting, Why Should I? What is the Risk? How Big Is the Problem? Where is the Problem?

Reporting, Why Should I? What is the Risk? How Big Is the Problem? Where is the Problem? Reasons Swiss Cheese Model

Organisational Influence Unsafe Supervision Pre-Condition for Unsafe Acts Unsafe Acts

Reporting, Why Should I? What is the Risk? How Big Is the Problem? Where is the Problem? Reasons Swiss Cheese Model

Organisational Influence Unsafe Supervision Pre-Condition for Unsafe Acts Unsafe Acts

How To Stop It Happening Again?

Consumers of Reports

Consumers of Reports Type I

Professionals Scientists/Researchers Duty of Care/

Organisation Staff

Consumers of Reports Type I

Professionals Scientists/Researchers Duty of Care/

Organisation Staff

Type II Fun Divers

Reasonss Swiss Cheese Model

Reporting, Why Should I?

Reporting, Why Should I? Data Provision


Safety conferences, lack of data


Safety conferences, lack of data Insurance and financial implication



Lessons Learned



Lessons Learned Needed to support Just and Reporting

Cultures - Feedback loop



Lessons Learned Needed to support Just and Reporting

Cultures - Feedback loop

Consistently similar problems or errors, likely to be an organisational or supervisory problem - Reason

Reporting Opportunities

Reporting Opportunities Online Forums

Reporting Opportunities Online Forums Training Agency Reporting

Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting

Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting DAN

Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting DAN BSAC

Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting DAN BSAC DISMS

DISMSDiving Incident and Safety Management

System

http://www.divingincidents.org

DISMS Open

DISMS Open Confidential

User Defined level of disclosure


User Defined level of disclosure Live database


User Defined level of disclosure Live database Online, secure web-based (+mobile)


User Defined level of disclosure Live database Online, secure web-based (+mobile) Independent


User Defined level of disclosure Live database Online, secure web-based (+mobile) Independent User conductible searches/exports

Demo of DISMS

Areas for Improvement

Areas for Improvement More Analysis Needed in Reports

Areas for Improvement More Analysis Needed in Reports Increase number of filter options

Areas for Improvement More Analysis Needed in Reports Increase number of filter options Improve drop down options esp CCR

Areas for Improvement More Analysis Needed in Reports Increase number of filter options Improve drop down options esp CCR Greater uptake from the user

community

Summary

Summary More opportunity for Lessons Learned


Easier to address than total stats capture, probably greater impact too



Needs stronger Reporting Culture



Needs stronger Reporting Culture But Just Culture essential to improve

reporting



Needs stronger Reporting Culture But Just Culture essential to improve

reporting

DISMS provides open, confidential and independent reporting system

Questions?

From a safety perspective, it is not criminal to make an error, but it is

inexcusable if you dont learn from it - Wiegmann/Shappell 2003

www.cognitas.org.uk http://www.divingincidents.org

Education

￼Culture. Isn’t just something that grows in the lab (or kitchen)

Culture. Isn’t just something that grows in the lab (or kitchen)