HF Skills in Diving Newsletter #10: News, Blog Updates, Courses and Just Culture...

Hey <<First Name>>

Welcome to the latest Human Factors Skills in Diving newsletter. Since the last newsletter there has been plenty going on behind the scenes generating content and arranging courses and seminars. This edition contains details of:

What is Just Culture and why is it so important?
Latest Blog Posts
Details of forthcoming classes.
Stand at Eurotek 2016
Presenting at DEMA Las Vegas
Presenting at OzTek 2017

“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.” Don Norman. Author, the Design of Everyday Things

When looking at failures we need to understand why it made sense for those involved to behave or operate the way they did. This example below shows why just telling people to do something 'right' isn't going to help improve performance or safety. We need to understand the 'Why'.

In 1943 the U.S. Air Force called in psychologist Alphonse Chapanis to investigate repeated instances of pilots making a certain dangerous and inexplicable error: The pilots of certain models of aircraft would safely touch down and then mistakenly retract the landing gears. The massive aircraft would scrape along the ground, exploding into sparks and flames. Despite numerous recommendations that were put forward for more training and close adherence to checklists, the issues continued. Chapanis interviewed pilots but also carefully studied the cockpits. He noticed that on B-17s, the two levers that controlled the landing gears and flaps were identical and placed next to each other. These levers are top right in this image.

Normally a pilot would lower the landing gears and then raise the wing flaps, which act as airbrakes and push the plane down onto the wheels. But in the chaos of wartime, the pilot could easily grab the wrong lever and retract the landing gears when he meant to raise the flaps. Chapanis’s solution: attach a small rubber wheel to the landing gear control and a flap-shaped wedge to the flap control. Pilots could immediately feel which lever was the right one, and the problem went away. In this case it was clear that the problem wasn’t the pilot, but the design of the technology that surrounded him.

Similar issues exist in diving - rebreather which has an o-ring that can be left out, a rebreather which has a canister system for the scrubber but no interlock to stop it being used without the canister, computers which have button sequences that mean if you miss a selection you have to cycle through again, BCDs that have controls which are non-intuitive for the majority of divers who might be rescuing the diver in question...

More...

Teaching Non-Technical Skills (Human Factors Skills) to Cardiothoracic Surgeons

Two weeks ago I was part of the faculty teaching new cardiothoracic surgeons non-technical skills using the GemaSim platform and a very similar framework to that delivered on the two-day diving class. The feedback received was great, recognising the benefit of teaching non-technical skills in a manner which meant that discussions were not focussed on clinical skills or outcomes and thereby leading to improved non-technical skills. Human Factors Skills, or Non-Technical Skills as they are known elsewhere, are essential to enable high performing teams and individuals to operate effectively, irrespective of role or environment.

New Blog Posts

Since the last newsletter, there have been four new blog posts.

Just Culture -The start of a short series looking at Just Culture and why it is so important to improving performance and safety.
Why is it so hard to talk about failure...? - Why we need to talk about failure and mistakes in a more public manner. We can't learn everything on a class, so we need experience (direct or indirect) to shape our decision making.
Local Rationality - Why we need to understand the context of the event if we are want to improve the system. Using a funny example of an elderly lady vandalising a piece of art to make the point.
Being a deviant is normal - Normalisation of deviance is a recognised term in the safety world. It happens all the time in the 'real world' when bad things don't happen and we reset 'safe'. We drift.

Eurotek 2016

This year I will have a stand at Eurotek 2016 but won't be presenting. I have done this to raise the profile of the courses and more importantly provide a means by which people can ask me anything about the courses or Human Factors Skills in Diving and why they should do them. I will be running short sessions between the presentations to get people thinking about Human Factors Skills in Diving. I am also running a two-day class immediately after Eurotek with only two places. Details here. There will be a Eurotek offer for the online class but you'll need to visit me on the stand to get it.

DEMA Las Vegas

I have two speaking slots at DEMA in Las Vegas on the Thursday and Friday (17 & 18 Nov). The first will be very similar to the presentation I gave at TekDiveUSA in April this year - the feedback from a number of people there was that it was the best presentation of the conference. The second will be a surprise as I am waiting for clearance to present! More details closer to the time.

OzTek 2017

I will be presenting at OzTek next March and am running two classes after the conference. The first on the Monday & Tuesday after the conference (20/21 Mar), the second on the weekend immediately afterwards (25/26 Mar). Locations will be fixed once I have a few more options but they will be in Sydney and will be added to the course date page. Three of the six places have already gone for the class on 25/26 Mar. My presentation at OzTek will be Human Factors-based and will likely be the results of the CCR Checklist study.

Planned Courses

Visit this page for details but I currently have courses with spaces in Birmingham (UK), Seattle, Orlando, High Springs, Sydney and at Inner Space 2017.

I often get asked can they share the newsletter. Of course you can. You don't need to ask. To make it a little easier, there are some other links which are useful to those interested in this subject.

Useful links to share

h ttp://www.humanfactors.academy - home page which has all the information that anyone will need including links to course dates at the top.
Two-page information leaflet about the classes provided and what Human Factors Skills in Diving is about
http://bit.ly/hfsdvideo - introduction video about Human Factors Skills in Diving classes.
http://bit.ly/hfsdnews - this newsletter sign-up and archive page.
http://bit.ly/hfsdblog - HF Skills in Diving Blog with plenty of useful tips and knowledge.

Safe Diving

Gareth