Checklists: If surgical teams don't comply, what hope do divers have?

[doctormike]

Agreed on the difficulty and limited utility of physical checklists for rec diving. As diving becomes more asvanced it’s a great situation for a mnemonic. However, the mnemonic or physical checklist, is only useful if people are trained to use them.

When stressed, rushed, tired, etc people fall back on their habits. If good habits are formed in training those habits will appear at the right time.

If CCR divers aren’t using checklists that already exist is it because they aren’t being trained to use them?

Do they stop using them because they don’t see a positive result from it? If you do something 100 times and you never detect a fault complacency sets in and use drops off?

Do they stop using them because the checklists are overly complicated or excessively long or difficult?

If it’s either of the first two, creating a new checklist is likely to be of little help. Continued reinforcement of the correct behavior is the answer. Peers need to hold each other to the correct procedure. A predive checklist, a mnenonic or physical list, is useful for the advanced and beginning tec level dives I do. They may be excessive for basic OW dives but I still do them every dive and with everyone I dive with. Whether a buddy, instabuddy or as a DM. Leading by example and holding others to the standard is what builds culture. That process needs to start well before a CCR enters the picture.

Sorry, I'm not sure I fully understand, although I do get that you think that checklists should be taught in OW class. Here are my points, to reiterate.

1) A simple, short PRE-JUMP checklist (not to be confused with a build checklist) is a good way of preventing a CCR diver from entering the water without the ability to maintain a PO2 setpoint due to a mechanical issue. This has been shown again and again to be a risk even to experienced CCR divers, and to be lethal without warning (unlike virtually anything that can happen on an OC dive not using a hypoxic mix).

2) Putting this simple little checklist ON your rebreather, in easy sight, so that it can be run down once you are wearing your unit makes it less likely that you will not do it because you didn't bring it, or because you don't want to seem like a newbie clutching one of those little clip on cards. So that's what I'm advocating.

3) This effort - changing the culture to get all CCR divers to use a physical pre-jump checklist - seems doable since we are talking about a very small population of very highly motivated individuals with strong community bonds.

4) While I do insist on three breaths from each regulator while looking at the SPG before getting in the water on OC, I don't see the need for a physical checklist in that case.

5) I can't imagine what it would take to get the vast number of divers getting OW training to start using physical checklists, either at the agency level or at the instructor level. But if you think that is a good campaign to begin (like I'm trying to do with #2 above), then have at it.

6) I think that mnemonics are terrible, in general. The very people who need them most are the ones most likely to misremember them. A physical checklist tells you exactly the same thing even if you are rushed, tired, hung over, sick, distracted or angry. Your brain simply doesn't do that.

 

[rjack321]

If CCR divers aren’t using checklists that already exist is it because they aren’t being trained to use them?

Do they stop using them because they don’t see a positive result from it? If you do something 100 times and you never detect a fault complacency sets in and use drops off?

Do they stop using them because the checklists are overly complicated or excessively long or difficult?

All of these apply and probably a few other reasons too. There's no one answer why not.

My guess would be rationale 2 and 3 are the most common reasons since #1 is a standards violation for every agency and manufacturer (but probably happens)

 

[Dsix36]

Each and every RB related course I took, regardless of agency, had the checklist protocol firmly in place, taught, and stressed by the instructors.

 

[doctormike]

Each and every RB related course I took, regardless of agency, had the checklist protocol firmly in place, taught, and stressed by the instructors.

Yup... Now we have to work on getting divers to use them after training!

 

[Diver-Drex]

@doctormike - your are trying to replace a checklist with a checklist. Maybe that helps you. If it helps you it is because you are committed to it. Maybe others will be too and that is commendable.

What you are missing is that a checklist or a mnemonic works because people are trained to use them and continue be compliant in their use. They are both tools that need to be used and used correctly. You are used to checklists, I’m sure from your profession. I am as well, but my experience tells me that training is what makes a checklist, mnemonic or any other procedure work.

This takes both initial and sustainment training. Formal training helps. Things like catching a potentially fatal fault with the checklist is very powerful sustainment training. Peer reinforcement of the behavior is very powerful sustainment training.

Unfortunately, when there is no immediate consequence to noncompliance that is also training. “I didn’t use the checklist yesterday and I didn’t die” leads to waning conformance. Or the “I knew that wasn’t quite right but nothin bad happened.” In your field the behavioral shift is exactly like alarm fatigue.

This is basic leadership stuff. Dogs, children, special operations soldiers, CCR divers and hospital staff...it doesn’t matter.

 

[Storker]

Trying include physical checklists into the training curriculum for basic OW divers sounds virtually impossible.

Even BWRAF is a checklist. Short, sure, not brought on physical medium, sure, but still a checklist.

As a diver, I'm pretty basic. Max 30m, no deco, no mixed gas, OC. Still, those times I've embarrassed myself by having to fix something that ought to have been squared before I even touched the water, it has been when I didn't go through my mental checklist properly. Although anecdote isn't data, I'm convinced that proper checklists are beneficial even for that kind of diving. Someone who has more dives than I have, or dives a lot mor often, may not need an explicit run-through of the checklist like I do, but I'm pretty certain they still check up on their gear somehow or other before splashing.

For simple OC dives, written checklists may not be necessary, but following some kind of (mental) checklist would probably eliminate quite a few of the idiot errors basic divers do and usually get away with. For longer, technical CCR dives, the list of things that ought to be checked may well have become so long that a written list makes perfect sense.

 

[doctormike]

@doctormike - your are trying to replace a checklist with a checklist.

I have no idea what you mean by that. I'm saying that every CCR diver should use a physical, pre-jump checklist. My particular idea is that the checklist should be unobtrusively glued to the side of your controller, where you can see it once you are in your unit. That way, it will ALWAYS be there, and if you are one of those people who has a problem being seen using a checklist for whatever reason, that will not be as much of an issue.

What you are missing is that a checklist or a mnemonic works because people are trained to use them and continue be compliant in their use. They are both tools that need to be used and used correctly.

Sorry, I don't get your point. I'm saying that CCR divers should use physical checklists, and my experience is that a lot of them don't, so that's why I'm making a big thing out of it and pointing out the tragedies that happen when they are not used. And it's also why I am trying to reduce two of the obvious barriers to use, as I mentioned above.

Yes, any piece of gear only works effectively if people know how to use it and remember to use it. I don't see how I am "missing" that, or how that in any way contradicts what I am saying.

You are used to checklists, I’m sure from your profession. I am as well, but my experience tells me that training is what makes a checklist, mnemonic or any other procedure work.

This takes both initial and sustainment training. Formal training helps. Things like catching a potentially fatal fault with the checklist is very powerful sustainment training. Peer reinforcement of the behavior is very powerful sustainment training.

Unfortunately, when there is no immediate consequence to noncompliance that is also training. “I didn’t use the checklist yesterday and I didn’t die” leads to waning conformance. Or the “I knew that wasn’t quite right but nothin bad happened.” In your field the behavioral shift is exactly like alarm fatigue.

This is basic leadership stuff. Dogs, children, special operations soldiers, CCR divers and hospital staff...it doesn’t matter.

Are you under the impression that I am recommending a physical checklist as a substitute for formal training and leadership? Because it sort of seems like that is what you are saying.

Once again. The day you show up to dive when you are sick, hung over, tired, preoccupied with new gear, angry at your spouse, nervous about a pinnacle dive, or whatever is the day that all of your training can go out the window in one brain fart. That can happen to CCR divers, surgeons or special op soldiers. It can happen to you. If you think that it can't, if you think that YOUR training will always protect you, you are wrong.

And THAT'S the advantage of a little piece of vinyl stuck on the side of your controller. It won't save you from every possible disaster. But it will ALWAYS tell you to turn on your O2 and see if your unit will hold a setpoint, no matter WHAT else is going on in your world.

 

[doctormike]

Even BWRAF is a checklist. Short, sure, not brought on physical medium, sure, but still a checklist.

NO!

This may be a semantic thing, but BWRAF is a mnemonic. And a mnemonic can fail. A physical checklist will always tell you the same thing no matter what (see my last response).

I'm a photographer. My first DSLR housing was an Ikelite, where there was an O-ring under the dome port that you had to remember to put in when you built the housing (unlike my current housing, in which the O-ring stays there until you take it out). I ALWAYS remembered to put it there. I was insanely compulsive about my photo gear, and I kept that O-ring clean and lubricated and checked it for nicks and everything. For years and years. Every single time. I could put that thing together in my sleep.

Until one day when I had a fight with my wife before going on a dive. And guess what happened? Flooded the camera.

I hate mnemonics. As I mentioned upthread, they are least reliable for the people who need them the most.

 

[Diver-Drex]

@doctormike - I am under no impressions. I have not said physical checklists aren’t needed. I’ve said, several times, that initial and sustainment training is needed if you’re trying to drive the long term behavioral changes needed to get people to comply with their use.

Over my 19 years in service, of which 14 were in Infantry and Special Operations units, I have seen training get people through a lot. Certainly mistakes happen but I am hear today because of my training and the training of those I served with.

I have tried to help you solve the question of why CCR divers don’t use the existing checklists and how to correct that. You continue to not see that. Maybe I’m not being clear. Or maybe you’re so stuck on your answer to the problem, yet another checklist, that you’re not able to even acknowledge another idea. Even if that idea is complimentary, not contradictory, to your own.

 

[Dr Simon Mitchell]

Hello,

This is an issue of great interest to me. I have been deeply involved in the development and application of the WHO Surgical Safety Checklist. I make this point only to establish my claim to some insight into the science of checklist use.

I think that one of the biggest problems with checklists in diving is confusion about what a checklist actually is (and is not). I often see divers referring to their use of a "build checklist" when assembling their CCRs, and it turns out that what they really mean is a couple of pages from the users manual with the relevant instructions. There is nothing wrong with this of course, but it only lasts until there is familiarity with the process, and then the divers almost inevitably abandon the written guide in favour of doing it from memory. Moreover, this is not a "safety checklist" in the way I would define it.

A true safety checklist is short, comprised only of items that address recognised "killer events", and is intended to be applied at a point in a process where safety-critical errors are known to have produced a disproportionate number of serious accidents. To me, the classic example of such a situation in diving is the use of pre-jump checklists in rebreather diving (as alluded to by doctormike). The pre-jump period is often time pressured and full of distractions, and there are 4 or 5 killer events (eg rebreather not switched on, oxygen cylinder off, dil cylinder off, drysuit inflator not connected) that have caused multiple fatalities which could have been prevented by application of incredibly simple checklists at that point.

Doctormike's suggestion of a written self-administered checklist mounted somewhere readable for use pre-jump is great. Even better is a simple check-and-response event performed with a second person (like a divemaster on a liveaboard). This has the highest probability of ensuring compliance and accurate application of the checklist. You don't even need someone who knows about rebreathers to do it (though that is preferable). You just give them the checklist and ask them to go through these items with you just before you stand up to jump in. I made an i-phone clutch-video of such an event with Mark Powell as the subject at the Ponza rebreather meeting a year or so back. We had never practiced it and there was only one take which sort of illustrates how easy it is to do; yet so powerful. Eagle-eyed viewers will see that it is not perfect, but it only takes 40 seconds, and if every rebreather diver did this before they entered the water quite a few deaths would be prevented. Please see here:

Dropbox - Checklist video.MOV

Simon M