BSAC 2019 Conference: Drs. Neal Pollock & Simon Mitchell (and more)
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This is a very convincing video, but since it's 48 min long, I thought I'd distill it down to the essentials for those who are short on time... (FWIW, there are several SB regulars who have stressed the same points over the years)
Executive Summary: use of a PHYSICAL (printed) checklist before each dive will prevent many major mishaps.
The talk focuses on Human Factors, rather than technical details (deco times, WoB, etc).
-> Proper use of checklists in Aviation and Medicine have led to significant decreases in "bad outcomes" (e.g. crashes, amputating the wrong leg, etc.)
• proper use of check lists is important (i.e. don't treat them as unimportant afterthoughts)
Change in how you think about / describe some human factors:
-> Don't say "mistake", say "error"
-> Don't say "bad choice", say "violation"
First, Violations: (these are CONSCIOUS CHOICES)
In an analysis of a RB instructor who died during a class, he summarizes:
"Violations do not arise from incompetence; they are a conscious decision not to follow teaching"
"The practice deficits that lead to this fatality involved choices that the diver knew were not optimal."
(the RB instructor in question SHOULD have called the dive when he realized his O2 readings were inconsistent).
Second, Errors:
(many examples given: mislabeled tank, jumping in with valves closed, etc)
Human Factors and Errors:
(Training, Protocols, Teamwork, Communications, Cognitive Aids) => checklists
Checklist – not an instruction manual, but lists only the most important “killer items”
Don’t rely on your memory for killer items, need a PHYSICAL check list (Cognitive Aid)
DAN checklist study shows MAJOR mishaps reduced by 36%(!) by using a physical checklist. (Although he feels the DAN checklist is too long / detailed).
***ALL trained divers KNOW the things on the checklist, but are often apt to either FORGET to check some of the points, or rush through others in the interest of time / expediency.***
-----
All "obvious" stuff, but I'm making a point of printing out and laminating a checklist for my trip next week with my daughter as my buddy. So what if it adds 45 seconds before we can jump in?
Executive Summary: use of a PHYSICAL (printed) checklist before each dive will prevent many major mishaps.
The talk focuses on Human Factors, rather than technical details (deco times, WoB, etc).
-> Proper use of checklists in Aviation and Medicine have led to significant decreases in "bad outcomes" (e.g. crashes, amputating the wrong leg, etc.)
• proper use of check lists is important (i.e. don't treat them as unimportant afterthoughts)
Change in how you think about / describe some human factors:
-> Don't say "mistake", say "error"
-> Don't say "bad choice", say "violation"
First, Violations: (these are CONSCIOUS CHOICES)
In an analysis of a RB instructor who died during a class, he summarizes:
"Violations do not arise from incompetence; they are a conscious decision not to follow teaching"
"The practice deficits that lead to this fatality involved choices that the diver knew were not optimal."
(the RB instructor in question SHOULD have called the dive when he realized his O2 readings were inconsistent).
Second, Errors:
(many examples given: mislabeled tank, jumping in with valves closed, etc)
Human Factors and Errors:
(Training, Protocols, Teamwork, Communications, Cognitive Aids) => checklists
Checklist – not an instruction manual, but lists only the most important “killer items”
Don’t rely on your memory for killer items, need a PHYSICAL check list (Cognitive Aid)
DAN checklist study shows MAJOR mishaps reduced by 36%(!) by using a physical checklist. (Although he feels the DAN checklist is too long / detailed).
***ALL trained divers KNOW the things on the checklist, but are often apt to either FORGET to check some of the points, or rush through others in the interest of time / expediency.***
-----
All "obvious" stuff, but I'm making a point of printing out and laminating a checklist for my trip next week with my daughter as my buddy. So what if it adds 45 seconds before we can jump in?
tmassey
Contributor
I just finished a Trimix class. Checklists were mentioned in the pre-class materials, and I took the opportunity to create some. We didn’t use checklists in class, but I independently used mine. On the 10 or so dives in and around class, I fixed at least three issues I would likely have splashed with. None serious, but all less than optimal. The only time I had a sub-optimal item was a time I skipped the checklist. That convinced me.
Mine is front and back of a credit card sized card (a blank ID card). One side is for gearing up, one is for sitting on the bench. I figure if pilots and nurses, who do something multiple times a day, benefit from them, so can I, when I do something about 50 times a *year*. I keep it with me the whole time: it slips into my drysuit pocket when I’m done with it.
Nothing complex: think GUEEDGE with equipment match list. (And helps me to do an entire GUEEDGE in under 3 minutes, if my buddy doesn’t turn it into story time — or take it over...). But, in my opinion, superior to mental mnemonics: a physical checklist is faster and more focused, even when it has more elements.
I’ve been mocked for having the checklists. But I’ve also had the checklist catch more than one error in *them* (just like in a GUEEDGE or START). Took a lot of self-control to not rub that in...
Mine is front and back of a credit card sized card (a blank ID card). One side is for gearing up, one is for sitting on the bench. I figure if pilots and nurses, who do something multiple times a day, benefit from them, so can I, when I do something about 50 times a *year*. I keep it with me the whole time: it slips into my drysuit pocket when I’m done with it.
Nothing complex: think GUEEDGE with equipment match list. (And helps me to do an entire GUEEDGE in under 3 minutes, if my buddy doesn’t turn it into story time — or take it over...). But, in my opinion, superior to mental mnemonics: a physical checklist is faster and more focused, even when it has more elements.
I’ve been mocked for having the checklists. But I’ve also had the checklist catch more than one error in *them* (just like in a GUEEDGE or START). Took a lot of self-control to not rub that in...
Scuba is a little like aviation in the barnstorming days. Back then, Dunning Kruger was in full effect, and pilots didn't know what they didn't know.
Checklists? Not me! Kick the tires and light the fires, and off we go!
Getting divers to adopt checklists with all their buddies watching them from the other side of the dive boat would be a little like that.
The data shows it's a safety enhancer. But peer pressure rules, for now. It took a long time before human factors analysis became mainstream in aviation.
The rebreather guys are helping change that paradigm, but it's slow.
Checklists? Not me! Kick the tires and light the fires, and off we go!
Getting divers to adopt checklists with all their buddies watching them from the other side of the dive boat would be a little like that.
The data shows it's a safety enhancer. But peer pressure rules, for now. It took a long time before human factors analysis became mainstream in aviation.
The rebreather guys are helping change that paradigm, but it's slow.
Both presentations are excellent.
One thing I noticed, is how the complexity of Rebreather training, saw the introduction of flash cards to advise the student what 'issues' they had to manage. This then migrated into open circuit technical diver training.
This migration of skills and practices is sometimes slow, but it does change the culture over time.
When I started diving, few boats carried their own O2 medical kits, we always brought our own. We still take our won kits, which often ends up back in the digs inmcase we get a symptomatic diver after the diving has finished. If a boat doesn't carry its own O2 we would have grave doubts about the competence of the skipper and crew.
I hope that peer pressure wouldn’t be high enough to prevent me to do a check list. (I have a fairly high public shame threshold and being disabled is usually an accepted excuse for being slower that everybody )
If my life is about to depend on a piece of equipment you can be sure that I'm going to follow a checklist to prepare before I go up (or down in this case )
But I don’t think I have nearly enough diving experience to produce a checklist efficient enough yet. Right now I stick to the BWRAF
)If my life is about to depend on a piece of equipment you can be sure that I'm going to follow a checklist to prepare before I go up (or down in this case
)But I don’t think I have nearly enough diving experience to produce a checklist efficient enough yet. Right now I stick to the BWRAF
OP
Jay
Need to dive more!
For most of my dives (all Rec) I generally see no full checks happening. I do see checks for air, and that's about it (of what's visible).
Which "carefully selected killer items" (quote from the presentation) does the DAN list (attached) or BWRAF have? I'd say none by themselves. The most severe is probably Air. Combinations, such as (no) Air and and an empty BCD/Wing might be slightly difficult. A triple combination, those prior two plus no fins, that could be lethal, but to get to that stage .... hmmm.
Which "carefully selected killer items" (quote from the presentation) does the DAN list (attached) or BWRAF have? I'd say none by themselves. The most severe is probably Air. Combinations, such as (no) Air and and an empty BCD/Wing might be slightly difficult. A triple combination, those prior two plus no fins, that could be lethal, but to get to that stage .... hmmm.
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