Culture. Isn’t just something that grows in the lab (or kitchen)...
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This presentation was given at the Eurotek 2012 technical diving conference and tries to highlight the challenges in changing and developing a safety culture within the sport of recreational and technical diving.
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Culture. Isn’t just something that grows in the lab (or kitchen)...
- 1. Culture. Isn’t just something that grows in the lab (or kitchen)... Improving Diving Safety Through Improved Reporting and a Just Culture Gareth Lock E: gareth.lock@cognitas.org.uk M: 07966 483832
- 2. Scope • Risk • Cultures • What is an Incident? • Reporting, why should I? • Case Studies • Reporting Opportunities • DISMS • Conclusions
- 3. Introduction • Full time RAF Officer (ex C-130 aircrew) • Adv Trimix Diver • Studying for PhD Cranfield • Cognitas in 2010 • DISMS launched Apr 2012
- 4. Risk, What is It?
- 5. Risk, What is It? • What is risk?
- 6. Risk, What is It? • What is risk? • Probability x Impact
- 7. Risk, What is It? • What is risk? • Probability x Impact • Acceptable level based on Experience, Attitude, Training and Culture...
- 8. Risk, What is It? • What is risk? • Probability x Impact • Acceptable level based on Experience, Attitude, Training and Culture... • Relative
- 9. Risk, What is It?
- 10. Risk, What is It? • What is risk?
- 11. Risk, What is It? • What is risk?
- 12. Risk, What is It? • Diving is risky • What is risk?
- 13. Risk, What is It? • Diving is risky • Baselines are required • What is risk?
- 14. Risk, What is It? • Diving is risky • Baselines are required • Understand the risks • What is risk?
- 15. Risk, What is It? • Diving is risky • Baselines are required • Understand the risks • Educate but don’t scare • What is risk?
- 16. Risk, What is It? • Diving is risky • Baselines are required • Understand the risks • Educate but don’t scare • Mitigate and reduce them • What is risk?
- 17. Risk, What is It? • Diving is risky • Baselines are required • Understand the risks • Educate but don’t scare • Mitigate and reduce them • To improve safety, not primarily reduce litigation • What is risk?
- 18. Risk, What is It? Incident
- 19. Risk, What is It? zIncident Safe Limit for Recreational Diving Safe Limit for Technical! Diving Safety Margin
- 20. Risk, What is It? zIncident Safe Limit for Recreational Diving Safe Limit for Technical! Diving Human Error! (Active/Latent)
- 21. Risk, What is It? z Resources Incident Safe Limit for Recreational Diving Safe Limit for Technical! Diving Human Error! (Active/Latent)
- 22. Risk, What is It? z Resources Incident Bad Luck! Safe Limit for Recreational Diving Safe Limit for Technical! Diving Human Error! (Active/Latent)
- 23. Risk, What is It? z Resources Incident Bad Luck! Safe Limit for Recreational Diving Safe Limit for Technical! Diving Human Error! (Active/Latent) Training
- 24. Risk, What is It? z Resources Incident Bad Luck! Safe Limit for Recreational Diving Safe Limit for Technical! Diving Human Error! (Active/Latent) Training Feedback
- 25. Risk, What is It? z Resources Incident Bad Luck! Safe Limit for Recreational Diving Safe Limit for Technical! Diving Human Error! (Active/Latent) Training Reporting Feedback
- 26. Cultures
- 27. Cultures • What are they?
- 28. 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)
- 29. Cultures • What are they?
- 30. Cultures • What are they? • Common Beliefs • Common Goals • Common Behaviours
- 31. Cultures
- 33. Cultures • Safety Culture • Reporting Culture • Just Culture • Informed Culture • Learning Culture • Flexible Culture
- 34. Safety Culture
- 36. Reporting Culture • Linked to Just Culture • Survey initiated as part of PhD
- 38. Reporting Culture Survey • Percentage of Divers Had Incidents? • Types of Incidents • Knowledge of the BSAC system • Reasons for not reporting • DCI Occur vs Report
- 39. 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
- 40. 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
- 41. 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%
- 42. 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#
- 43. 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#
- 44. 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)'
- 45. DCI vs Reporting • 2010 BSAC Figures: 105 • 2010 BHA Chamber Recompressions ~350 • DDRC Study 2002 - ~45% self diagnosed DCI didn’t reported to chamber • 2012 Reporting Survey • Tech Only (#349), DCI Yes - ~25% • All Instructors, DCI, not chamber - ~10%
- 47. Reporting Culture • Improvements are needed
- 48. Reporting Culture • Improvements are needed • Guidelines on what is an Incident • Independence may improve uptake • Easy to submit report • Useful outputs • Promotion of Reporting
- 49. Reporting Culture • Improvements are 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
- 50. Just Culture
- 51. Just Culture • Not ‘no blame’
- 52. Just Culture • Not ‘no blame’
- 53. 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’
- 54. 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’
- 55. What is an Incident?
- 56. 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.
- 57. 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.
- 58. What is an Incident?
- 59. What is an Incident? • Unplanned separation at depth, solo ascent
- 60. What is an Incident? • Unplanned separation at depth, solo ascent • OOG back gas just before end of BT
- 61. What is an Incident? • Unplanned separation at depth, solo ascent • OOG back gas just before end of BT • Twin indies, end dive 20bar/210bar
- 62. 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
- 63. 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
- 64. 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
- 65. 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
- 66. 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
- 67. 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
- 68. 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
- 69. What is an Incident?
- 70. What is an Incident? • 10% Lack of Clarity • More guidance required
- 71. 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
- 72. Case Study One MCCR Shutdown Image from www.kissrebreathers.com
- 73. Case Study One MCCR Shutdown • Experienced Trimix Instructor, Relatively New CCR Diver Image from www.kissrebreathers.com
- 74. Case Study One MCCR Shutdown • Experienced Trimix Instructor, Relatively New CCR Diver • Forgetting O2 shutdown post dive Image from www.kissrebreathers.com
- 75. Case Study One MCCR Shutdown • Experienced Trimix Instructor, Relatively New CCR Diver • Forgetting O2 shutdown post dive • Shutdown O2 progressed from dekitting to ‘on lift’ Image from www.kissrebreathers.com
- 76. Case Study One MCCR Shutdown • 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 Image from www.kissrebreathers.com
- 77. Case Study One MCCR Shutdown • 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 • PPO2 0.07 on lift Image from www.kissrebreathers.com
- 78. Case Study One MCCR Shutdown Image from www.kissrebreathers.com
- 79. Case Study One MCCR Shutdown • Reported: Diver shutdown O2 in water. Broke ‘rules’. Image from www.kissrebreathers.com
- 80. Case Study One MCCR Shutdown • Reported: Diver shutdown O2 in water. Broke ‘rules’. • Not one reason for incident, back story possible to understand WHY Image from www.kissrebreathers.com
- 81. Case Study Two CCR Narcosis
- 82. Case Study Two CCR Narcosis • Experienced MOD 3 level CCR Diver
- 83. Case Study Two CCR Narcosis • Experienced MOD 3 level CCR Diver • Stressful previous days
- 84. Case Study Two CCR Narcosis • Experienced MOD 3 level CCR Diver • Stressful previous days • Issues on descent, carried on despite ascending to clear
- 85. Case Study Two CCR Narcosis • Experienced MOD 3 level CCR Diver • Stressful previous days • Issues on descent, carried on despite ascending to clear • CO2/N2 Narcosis and bailed out, then problems started!
- 86. Case Study Two CCR Narcosis • Experienced MOD 3 level CCR Diver • Stressful previous days • Issues on descent, carried on despite ascending to clear • CO2/N2 Narcosis and bailed out, then problems started! • Fortunately resolved at 21m on OC bailout after 20mins
- 87. Case Study Two CCR Narcosis
- 88. Case Study Two CCR Narcosis • Likely Reported: Potential narcosis leading to bailout
- 89. Case Study Two CCR Narcosis • Likely Reported: Potential narcosis leading to bailout • Not one reason. Many opportunities to stop incident developing. Full story required to understand WHY
- 90. Reporting, Why Should I?
- 91. Reporting, Why Should I? • What is the Risk?
- 92. Reporting, Why Should I? • What is the Risk? • How Big Is the Problem?
- 93. Reporting, Why Should I? • What is the Risk? • How Big Is the Problem? • Where is the Problem?
- 94. Reporting, Why Should I? • What is the Risk? • How Big Is the Problem? • Where is the Problem? • Reason’s Swiss Cheese Model • Organisational Influence • Unsafe Supervision • Pre-Condition for Unsafe Acts • Unsafe Acts
- 95. Reporting, Why Should I? • What is the Risk? • How Big Is the Problem? • Where is the Problem? • Reason’s Swiss Cheese Model • Organisational Influence • Unsafe Supervision • Pre-Condition for Unsafe Acts • Unsafe Acts •How To Stop It Happening Again?
- 97. Consumers of Reports • Type I • Professionals • Scientists/Researchers • ‘Duty of Care’/ Organisation Staff
- 98. Consumers of Reports • Type I • Professionals • Scientists/Researchers • ‘Duty of Care’/ Organisation Staff •Type II •‘Fun’ Divers
- 99. Reasons’s Swiss Cheese Model
- 100. Reasons’s Swiss Cheese Model
- 101. Reporting, Why Should I?
- 102. Reporting, Why Should I? • Data Provision
- 103. Reporting, Why Should I? • Data Provision • Safety conferences, lack of data
- 104. Reporting, Why Should I? • Data Provision • Safety conferences, lack of data • Insurance and financial implication
- 105. Reporting, Why Should I? • Data Provision • Safety conferences, lack of data • Insurance and financial implication • Lessons Learned
- 106. Reporting, Why Should I? • Data Provision • Safety conferences, lack of data • Insurance and financial implication • Lessons Learned • Needed to support Just and Reporting Cultures - Feedback loop
- 107. Reporting, Why Should I? • Data Provision • Safety conferences, lack of data • Insurance and financial implication • 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
- 109. Reporting Opportunities • Online Forums
- 110. Reporting Opportunities • Online Forums • Training Agency Reporting
- 111. Reporting Opportunities • Online Forums • Training Agency Reporting • Manufacturer Reporting
- 112. Reporting Opportunities • Online Forums • Training Agency Reporting • Manufacturer Reporting • DAN
- 113. Reporting Opportunities • Online Forums • Training Agency Reporting • Manufacturer Reporting • DAN • BSAC
- 114. Reporting Opportunities • Online Forums • Training Agency Reporting • Manufacturer Reporting • DAN • BSAC • DISMS
- 115. DISMS Diving Incident and Safety Management System http://www.divingincidents.org
- 116. DISMS
- 117. DISMS • Open
- 118. DISMS • Open • Confidential • User Defined level of disclosure
- 119. DISMS • Open • Confidential • User Defined level of disclosure • Live database
- 120. DISMS • Open • Confidential • User Defined level of disclosure • Live database • Online, secure web-based (+mobile)
- 121. DISMS • Open • Confidential • User Defined level of disclosure • Live database • Online, secure web-based (+mobile) • Independent
- 122. DISMS • Open • Confidential • User Defined level of disclosure • Live database • Online, secure web-based (+mobile) • Independent • User conductible searches/exports
- 123. Demo of DISMS
- 124. Demo of DISMS
- 126. Areas for Improvement • More Analysis Needed in Reports
- 127. Areas for Improvement • More Analysis Needed in Reports • Increase number of filter options
- 128. Areas for Improvement • More Analysis Needed in Reports • Increase number of filter options • Improve drop down options esp CCR
- 129. 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
- 130. Summary
- 131. Summary • More opportunity for ‘Lessons Learned’
- 132. Summary • More opportunity for ‘Lessons Learned’ • Easier to address than total stats capture, probably greater impact too
- 133. Summary • More opportunity for ‘Lessons Learned’ • Easier to address than total stats capture, probably greater impact too • Needs stronger Reporting Culture
- 134. Summary • More opportunity for ‘Lessons Learned’ • Easier to address than total stats capture, probably greater impact too • Needs stronger Reporting Culture • But ‘Just Culture’ essential to improve reporting
- 135. Summary • More opportunity for ‘Lessons Learned’ • Easier to address than total stats capture, probably greater impact too • Needs stronger Reporting Culture • But ‘Just Culture’ essential to improve reporting • DISMS provides open, confidential and independent reporting system
- 136. Questions? “From a safety perspective, it is not criminal to make an error, but it is inexcusable if you don’t learn from it” - Wiegmann/Shappell 2003 www.cognitas.org.uk http://www.divingincidents.org