"Human Error" or "Diver Error": Are they just an easy way of blaming the individual?

[GLOC]

I agree with Parker Turner's situation. A rarity.

If we classify everything as 'human error' how does that help us resolve the situation?

A: Looking at this case. Destructive goal pursuit (totally focussed on the goals, despite everything else saying stop). Self (over)-confidence. Group-think - supporters didn't want to not support. Lack of assertion within the team to say 'stop' this is madness. Lack of awareness of what might have gone wrong and plan accordingly. Assumption that everything would go to plan.

B: Running out of gas is an outcome, not a cause. Why did they run out of gas? Poor awareness that tank wasn't full to start with. Task fixated so didn't notice consumption. Didn't notice equipment leak. Freeflow and couldn't shutdown. Teamwork didn't help resolve the situation. The checklist study from DAN showed that less than 7% of divers used a checklist prior to a dive. That doesn't sound like an individual problem, that sounds like a system problem!!

Incompetent and unaware can only be corrected through reflective debriefs and that is what D-K showed. If you were are of your own limitations, then you can start to correct them. How much of the 'modern' recreational training is about reflective personal development compared to 'monkey see, monkey do' training? To develop thinking divers we need to create those who learn through 'second-loop learning' understanding 'why' something is done a certain way, not just doing something by rote and because the instructor said do this because you need to complete this task to pass the course.

So back to your point

a) failed to avoid putting yourself in a situation that you were not prepared to handle adequately (avoid)
or
b) you failed to correctly handle a situation you *thought* you were prepared for (cure)

A: How do you know what you are prepared to deal with before the event? If they knew this, they wouldn't likely do that. What about peer pressure to not thumb a dive, hoping it would be okay? The ability to thumb a dive at any time for any reason is based on personal confidence and experience. I have worked on Oil rigs where the crews are given a 'Stop Work Authority' card which is signed by the CEO and they can hold up and say 'Stop'. How often does it get played? Hardly ever because people are afraid of doing so. And that is where the consequences can be very large!! Giving people the tools is fine, but they need to be able to operate them in the social environment they are in.

B: Again, if you thought you were prepared, you thought you were prepared, so you thought it would be ok. Only in hindsight do we see that it wasn't right...

As I have posted elsewhere, Dunning-Kruger also impacts those in the top quartile of a performance group - instead of overestimating their own capabilities, they make assumptions about what those at the bottom quartile should know and do...

It is not an easy problem to solve...especially when the concept of 'safety' and 'risk' are very much at a personal level.

 

[Diver0001]

I agree with Parker Turner's situation. A rarity.

If we classify everything as 'human error' how does that help us resolve the situation?

Well... Gareth, I don't have the benefit of your background so you have me at a disadvantage in this discussion, but in my mind it's not that complicated.

I think as soon as we admit that almost all diving accidents are due to human error then it really helps us, as instructors, to focus on what is important.

I mentioned above that it all seems to fall into two "pigeon holes" to me. Either "failure to avoid" or "failure to cure".

I think if we were to look back from accidents that are well understood that we can reach one of these two root causes in (almost) all cases. That must help us a lot because if we were to do this in a large number of cases then it would soon become evident which skills were lacking that contributed to "failure to cure" and which behaviours were factors in "failure to avoid".

This information would be very valuable from a training perspective because if we were more attuned to recognising risk factors that were supported by evidence (as opposed to opinion) then we would be in a better position to address them. As it is, what I do with OW students is to address "failure to avoid" and "failure to cure" in a more generic discussion about comfort zone and the importance of ongoing practice and skills refinement as part of being a conscientious diver. If the world were perfect and I were to understand based on root causes, which behaviours I should be looking for and addressing more specifically, then I think it would help me to single out those students who needed this attention and my effectiveness as an instructor would be improved.

For example, as I said above I address "failure to cure" the way I teach the course but not only as platitudes about practice makes perfect and such. I've developed something I call my "ABC rule" for keeping thinking straight, getting the right priorities dealt with first and keeping the task chain from "bunching up" when stuff happens. I give this rule attention at several points during the course and integrate it into the way I teach skills like air sharing and such. I do this because I know from experience that it helps me and I assume that students who learn the ABC rule are less likely to do the wrong thing first when the proverbial sht is hitting the fan. However, I have no way of knowing if that approach is justified based upon root cause analysis of well understood accidents. What I'm doing is all intuitive.

So that's what I think would change if we classify everything as human error (or admit that this is probably the case). Better understanding of the root causes would give us a much better understanding of where to put the focus.

Naturally as you point out, personal factors with regard to risk aversion/acceptance are things we can't and should not want to train. The best we can do is to give the student sufficient understanding of what they are doing that they get out of "unware/incompetent" to a situation where they can properly assess their own skills in relation to the environment.

R..

 

[Bob DBF]

On the other hand, I think that a lot of people do (a) because they are unaware of their incompetence. This is what we call "getting in over ones proverbial head". I think a lot of recreational accidents could be avoided as well if more diver's were more aware of their actual level of competency. The ground we can win here is enormous because getting out of this phase of being "incompetent and unaware" is part of a normal learning process and can be taught.

...and was taught when I started diving and later when I took OW. More attention was put on water skills and the underlying fact that SCUBA diving puts you in an unsafe environment. Discussing common, and uncommon, issues and strategies to deal with them took up more hours of classroom time than did discussing the diving manual. This and countless hours in the pool, made the new diver more thoughtful when pushing the limits, and better prepared to deal with an emergency without immediate panic. Neither instructor was big on harassment, but would elevate your task load and run real emergencies in the pool sessions so you would have a realistic view of your own competence.

It is not an easy problem to solve...especially when the concept of 'safety' and 'risk' are very much at a personal level.

And will not be solved as long as SCUBA is considered extremely safe, and OW and AOW take a minimal amount of time and effort.


Bob

 

[Diver0001]

...and was taught when I started diving and later when I took OW. More attention was put on water skills and the underlying fact that SCUBA diving puts you in an unsafe environment. Discussing common, and uncommon, issues and strategies to deal with them took up more hours of classroom time than did discussing the diving manual. This and countless hours in the pool, made the new diver more thoughtful when pushing the limits, and better prepared to deal with an emergency without immediate panic. Neither instructor was big on harassment, but would elevate your task load and run real emergencies in the pool sessions so you would have a realistic view of your own competence.\

Well, I do not necessarily subscribe to the idea that if a course is longer or made to be more difficult that it is automatically better. I've seen instructors run long and difficult looking courses, telling students the whole time how dangerous and difficult diving is, and at the end of the day, their results were no better than the average instructor, aside from the fact that his students were more anxious, albeit hyper alert.

I also live in the Netherlands where the traditional training from the NOB (local CMAS) was very long indeed. My daughter's boy friend has been working on his OW for 4 years. I should say that he has an old school instructor and that the new NOB approach does not do that anymore. Nevertheless, there comes a point where you have to get the hell out of the pool and go diving..... in this case the instructor made his course very very long without making it very very good. The point being that the assumption that "longer is better" is really a game of diminishing returns.

That said, I do absolutely agree with you that the students have to learn how to deal with task loading. I train this in the current PADI OW course by using a series of increasingly complex tasks involving balancing golf balls on spoons or on other golf balls (yes, under water this does work) while swimming etc..... I also use tiny hockey sticks and pucks and various other ways of distracting a student while they are diving to teach them a very important lesson, namely that when their attention is off of their buoyancy control that this is the first thing they will lose control of..... it's an integral part of teaching the ABC rule. I then go on to show them how they can combine tasks effectively by chaining and how that chaining can be used to "drop" or "delay" a non-essential task when something more important is happening. (Also part of ABC). PADI says "stop think and do". What the ABC rule is, is just a very deep working through of the step "think".

Therefore I have no trouble teaching task loading exercises within the context of standards in this way. I don't need to be ripping off their mask without warning, for example, to get them to have to juggle tasks or to learn how to do it effectively.... and/or without becoming anxious in the process.

As an aside, in other courses I continue to do this. I recently had a student who wanted to do AOW. The shop offered him PPB but said that his buoyancy control was perfect and couldn't be improved. I challenged that and bet him that I could get him to lose buoyancy control within a minute. He took the bet and it was really very simple. I took him on a descent in the "green" (alas, we do not dive in "the blue" here) and stopped him 1/2 way to the bottom. I then told him to navigate a course and within a minute his depth had changed by 5 meters. This was simple task loading and because he had never learned to combine buoyancy control (in this case without a visual reference) with another task, he couldn't do both. He decided to do PPB, which wasn't my goal necessarily, but it did give me the chance to teach him what he needed to know.

To me it's really a shame that this kind of thing isn't more laid out for instructors. I think quality could be improved a lot by developing these aspects of learning to dive more and I can't help wondering if it happens because so many instructors don't have the background to know how to handle task loading very well themselves, let alone teach it.

And will not be solved as long as SCUBA is considered extremely safe, and OW and AOW take a minimal amount of time and effort.

But Bob, scuba diving IS very safe, if you have learned how to dive safely. The problem arises when people are told that they have learned to dive safely when they have not.

R..

 

[GLOC]

The original aim of my PhD was to look at the role of human factors in diving incidents and accidents. However, the lack of quality data put that idea down The idea was to create something like the HFACS model which was used to turn 'pilot error' in 300 USMC aviation accidents into something which they could try to fix.

This is the top level diagram

The bottom row is what most people focus on which is expanded here. Unfortunately, many of the latent, supervisor and organisational issues set people up for the fall.

So without classifying an incident into something other than 'human error' we miss all of the solutions to potentially fix the problem.

However, the problem with simple classification like this is that 'risk' and 'unsafe' are emergent properties. By that I mean you could have a situation where 2 + 2 > 4. Each of the individual factors on their own isn't an issue, but when you combine them, the sum is greater than the parts. Humans are rubbish at spotting small changes and it is those small changes which combine which bite us in the bum!!

Regards

 

[GLOC]

But Bob, scuba diving IS very safe, if you have learned how to dive safely. The problem arises when people are told that they have learned to dive safely when they have not.

R..

But 'safety' is a personal concept. The same as risk is. Therefore what I consider to be safe, may not be what you consider safe. If I have a free flow of a twinset reg at 75m whilst on trimix and 30mins of deco above me, do I consider that unsafe or risky? Probably not. Does a newly qualified AOW diver swimming through an aircraft in an inland quarry at 30m on single cylinder having a free flow due to cold water think it was unsafe/risky...probably, depends on how low his gas got!

A simple question before I go to bed! When you drove into work this morning, how did you know you were safe? Was it while you were driving? Was it when you got to work and didn't have an accident or close call? Safety and risk are often judged after the event. And if nothing went wrong, do you have the same concept of risk/safety?

Good discussion guys...thanks

 

[Bob DBF]

Well, I do not necessarily subscribe to the idea that if a course is longer or made to be more difficult that it is automatically better.

However making a class, of any type, shorter does not increase the amount of material that can be taught. Making any class more difficult than it needs to be is counterproductive, however making a class easy just to quickly certify students and move to the next group is worse. There is no way to remove bad instructors and DM's.

Therefore I have no trouble teaching task loading exercises within the context of standards in this way. I don't need to be ripping off their mask without warning, for example, to get them have to juggle tasks or to learn how to do it effectively.... and/or without becoming anxious in the process.

I have not had a mask ripped off, in training, but did have it dislodged in training, in the same manner that a fin kick would do in real life. Changing your task loading is one thing, actually having an issue is completely different.

To me it's really a shame that this kind of thing isn't more laid out for instructors.

Without quality control of dive professionals on the part of the agencies and removing bad instructors, the bar will remain low. The good news is that we don't lose many divers each year.


Bob

 

[Diver0001]

Fair enough, Bob. Obviously courses that are too short are a problem. You're right about that. The main thing is that courses are not SUPPOSED to be time driven at all. All agencies in scuba diving write their standards from a fundamental philosophy of "performance based learning".

What "performance based learning" means is this: contrary to a traditional course like we all had at school, time is not fixed. At school, courses took X amount of time and you get a grade at the end of time allotted. In a performance based, system, however, competency is not variable. There is a definition of mastery and everyone should be taught to master everything. In diving courses that means that we don't stop until the student can perform every skill to the agency's definition of mastery and they understand the theory to 100% comprehension.

In other words, in a performance based system, time IS variable.

The biggest issue the industry faces has to do with this. A shop cannot build a business model based upon a performance based system. Why? Because when a customer comes into the shop and asks the main three questions on their mind as a consumer, namely
a) how long does it take?
b) how much does it cost?
c) what do I get when I'm done?

Then the shop CANNOT ANSWER with
a) we don't know
b) we don't know
c) a certification with guaranteed competency.

Any shop that answers questions (a) and (b) with "we don't know" is not going to last very long. Therefore they price the course to fix in a fixed (or very slightly variable) time frame and quality, once again, becomes the variable. Plainly put, it is much easier for a shop to sell a customer variable quality than it is for them to sell the customer variable cost (or time).

This MASSIVE disconnect is the reason that training is the way it is. Looking at the tree Gareth posted above you can see that this disconnect is happening very high in his tree. It is namely, an organisational influence that is trickling down all the way to the point at which accidents happen in the water.

As an aside to this, I've had two chances so far to teach the PADI OW course without any time frame at all and I'll tell you what happened. Both were courses that I taught using shop facilities but one of the students was a niece and one of them was my daughter. In both cases I paid the shop a fixed price for the course to cover their expenses and told them that I was going to approach it with no fixed dead line. They agreed.

In the case of my niece she did the course over 6 pool sessions of 75 minutes and 6 or 8 dives in open water spread over one summer. I am a better, more efficient, instructor now than I was then but this was more than enough time to train her. In her last pool session I asked her to repeat some skills while hovering and she did things like the mask R&R while maintaining a perfect hover.

With my daughter I did something slightly different. When I told her she could start her training I took her 2 or 3 times in the pool and just swam around with her to make sure her mask and regulator skills were sorted and that her understanding of buoyancy control and BCD usage was ok. Then I just took her to the pool with me while I was training other people and told her to swim around and do her own thing while I was working. This was possible at the shop where I work because we usually have 1 or 2 free-ranging divemasters in the pool who maintain supervision in the "big picture". I did this regularly for a year or so. It was actually her that invented some of the "task loading" games that I use with the golf balls etc. during this time.

When she turned 14 I told her I would certify her and we finished the course. I ran through all of the skills she needed to know for the OW course in 3 sessions in the pool (more than I needed) and then started diving with her in a nearby lake. Again, this was just "tagging along" but in the process I fine-tuned her skills and eventually ticked them all off. Everything was done in the way and the order that PADI standards demand but spread over about 18 months. Her last dive before I certified her was in the pool. I gave her a list of all the skills she had learned and told her, like I told my niece to try doing some of them while hovering motionless. She likes a challenge and she's been doing theater since she was little so when we got under water she took a traffic pylon that was standing on the bottom and put it on her head and then proceeded to do something like 15 skills in sequence with a sort of tin-man soldier routine, while hovering. The last skill was the mask off/on and she set the pylon on the bottom for that. When the mask was back on she gave me a big tin-man salute to signal that she was done. At no point did the hover break. In fact one other instructor who was in the pool stopped what he was doing in the middle of course to watch this with his students. It was really spectacular and of course I was a proud as hell.

So this is what mastery CAN be if you apply the PADI standards AND you apply performance based approaches. Unfortunately we have to deal with the commercial realities so even reasonably good instructors can end up over time, redefining their *personal* definitions of mastery. In fact, this can happen two ways. Some people will become more lacks and others will become overly strict. I tend to be the latter unless I hold myself back, along with several other instructors on Scubaboard, (Jim Lapenta springs to mind) but sadly, lowering the bar is more common. This isn't an agency thing in itself, but the agencies MUST be aware of this "decalibration" happening among instructors. I would like to see them address that some how.

R..

 

[AfterDark]

Sign of the times? In 1968 the only dive shop within 30 miles had a policy if you didn't learn and preform in the allotted time and whatever extra time the instructor might allow then you weren't certified and no refund. To this day I remember how concerned I was about being unable to clear my mask with one breath (no scuba) and how I'd get washed out before I even got to put a tank on! Since my father who was not a rich man was paying I was twice as motivated to learn. After begging the life guards at the YMCA pool to allow me be practice clearing my mask for a week everyday after school (high school) I finally was able to satisfy my instructor.

Whether that was the times or that instructor I don't know but I can still clear my mask with one breath!

 

[Diver0001]

Maybe.....

My personal philosophy is that if a student wants to learn how to dive and I don't see any really compelling reason why that is a bad idea, then I'm willing to put in as much time as it takes. I have an ex colleague who I respect very much for her skill as a diver and as an instructor, but she was one of the most jittery OW students you've ever seen.....

In other words, this idea that diving should somehow be a sort of club that is hard to get into is not something I necessarily agree with. That said, I have turned students away, or refused to train them further, because I did not believe that I was in a position to train them to standards. A couple of examples of this are :
- a student who utterly refused, even after many corrections and repetitions, to stop using his BCD power inflator to "launch" his ascent. It came to a head during the OW portion of the dive where I thought the coin might finally fall. It did not. He simply liked the feeling of the fast ascent. I made one dive with him in OW and stopped his training.
- a woman who was almost literally dragged by the hair to the diving course by her boyfriend. She cried during the first pool session and subsequent debriefing in private revealed what was going on. We refunded her money. The boyfriend nearly attacked me. I felt sorry for her because it was obviously an abusive relationship but we couldn't do anything about that.
- a boy who could "mechanically" do all table questions correctly but was utterly and completely unable to explain how to plan a dive. If someone wasn't telling him what to do, he couldn't do it. This went on for 5 weeks at which point I said to his mother that she needed to let him wait a year. She went ballistic and nearly attacked me.
- a woman who came for a try-dive and revealed just before we went to the pool that she was utterly terrified of water and wanted this experience because of that. After the session she wanted to sign up immediately for OW. I said no but that she was welcome to come back once she had earned a swimming diploma. She never came back.

One case that I did persevere with that I still have my doubts about was a student who had been sent away by several other instructors already. She came to me via the shop and the owner asked me to dive once with her in the pool and diagnose her problem. I did the dive and saw that her only real problem was learning to tolerate water in the mask. I spent several hours with her after that talking with her about her life and I realized that there was no trauma involved so I thought that this problem could be tackled, but with no fixed time line. So she paid per session and we dove and dove and dove together. In the end it took her 20 hours in the pool and another 20 dives in OW before I felt that she was at a point that she should deal with water in her mask, even when it happened unpredictably. Part of her training also involved mediation practice and other "stress management" strategies (something I know about from my real-life) so I added this to help her move along more quickly. Eventually I certified her. She never intended to become a diver but she wanted to go through this process as a matter of personal growth. When I told her that I was going to certify her she started to cry and said that there were only two people in this world who understood her. Her father, and me. I was shocked by that. This course became a lot more to this student than anything a diving course should ever have been but it fit with the idea I had that you should do anything you can as long as the student doesn't want to give up.

Faced with the same situation again, I would be very inclined to refer her to a psychologist instead of a diving instructor and I probably would refuse to train her now that I have more experience as an instructor.

R..