Checklists, Crew Resource Management and Situational Awareness

Checklists, Crew Resource Management and Situational Awareness – these are all terms you would expect to hear in an aviation environment, they are also starting to appear in other environments such as medicine as demonstrated by the Horizon documentary last night in the UK.  The idea being that the lessons that have been learned in high pressure and high risk scenarios (aviation, firefighting and Formula 1) can be transferred to medicine.  With my military aviation background, I couldn’t see why the same couldn’t be done in sport diving, which is why I set up Cognitas in 2011.

During the presentations I give on Human Factors in Diving Incidents, I try to relate these concepts to a diving context.  

Situational Awareness – where divers need to be aware of changes in their environment or dive plan, their team or their equipment and the impact that this may have on the plan in the future. e.g. if the current is taking them further down current than planned in the same time scale, they need to turn back sooner if they are to maintain their gas reserves; if one diver is breathing much heavier than normal, their minimum gas to end the dive will be increased as will their buddy’s so that needs to be communicated; if the visibility is deteriorating because of divers in front of them, go around or over the silt, don’t swim through it.  These all impact the dive plan and reduce safety margins. If things are going exactly to plan, think about the implications and what needs to be done ahead of the game, before the incident develops.

Crew Resource Management (CRM) – This is more than teamwork – this is working together using strengths and weakness of the team, respecting that anyone can call a dive at any point and can question anything at any time. By creating an environment where hierarchy or authority gradients are removed, it allows a more junior diver to question what a more senior/experienced diver is doing if it looks like a mistake is happening or going to happen. When CRM was introduced to aircrew in the RAF in the early ’90s, there was a significant amount of resistance from senior officer aircrew who didn’t see the need and thought it was a complete waste of time – ironically, it was exactly those aircrew who needed to be taught about CRM and to adopt it in their daily flight operations.  An example would be a senior regional instructor or diving officer about to make a fundamental error putting their kit together which they have not spotted but would have consequences later on in the dive if nothing was mentioned by the junior diver looking on. The junior diver needs to be able to ask a question about why or how the kit has been configured that way without fear of retribution or humiliation.  Lessons are learned when we recognise that we have made a mistake and decide that we need to learn – if we aren’t responsive or stubborn, we won’t adapt, learn and improve.   

Checklists – This subject was one of the consensus opinions at Rebreather Forum 3.0 where it was recognised that checklists improve safety. However, it should be noted that one checklist will not cover all scenarios and the ‘pilot’ checklists which were adopted in the World Health Organisation programme are ‘last ditch’ checklists to make sure that major issues haven’t been missed – like operating on the wrong leg or the wrong patient!

(Crucially, the trial in the WHO programme only worked because hospital management allowed nurses to stop procedures if checklists hadn’t been completed, irrespective of the seniority of the surgeons involved. (CRM!))

Checklists in diving can be simply following BWRAF or GUEEDGE as a last mnemonic to prepare your equipment before getting in the water.  When I mentioned the RF3.0 checklist position on a couple of forums, many comments were raised saying that they are a waste of time, but there are certainly examples of incidents and fatalities which would have been prevented if the diver was using one.  However, producing a checklist is not enough – you need to get the diver to use one and this needs to be lead from the top down through all levels of instruction and training such that it becomes the norm, not just something which you do when someone else is watching.

The Horizon clip showed was interesting because it missed out all of the positive organisational structures which are present in aviation; management knows that safety is paramount in civil aviation and commercial pressures needs to take a back seat. Someone referred me to this link 

Sir – Mr Griffiths makes a valid point about checks on doctors’ competence (letter, Aug 28).

However, I doubt whether as a pilot he is required to take to the skies daily with a plane grossly overloaded with passengers, with its safety systems either out of date or disconnected awaiting investment needed for upgrading or repair, with barely enough fuel to complete his journey and engines with known faults but a cheery assurance from the ground crew that they will probably make it.

Add a dirty cabin with only one member of crew to look after all the passengers, and adverts from the employing airline saying how wonderful they all are and he will begin to get a taste of life as a doctor in the NHS today. Oh, and try taking off on another flight before the original has landed so that he can supervise his junior officers on both planes and then sit down to answer personally the complaints about the bumpy landing.

which identifies shortfalls in public medicine. It is likely that private medicine is not as effected by commercial pressures as they just resource properly and charge the patient accordingly. 

Safety Culture – The same organisational challenges are also faced in diving. Or even more so because we have no formal authoritative organisational structure across the whole diving community to take charge and recommend positive change; that doesn’t mean mandate or legislate, it means setting a common and coherent example of what is best practice.  On more occasions than not, we ‘get away with it’ and as a consequence, we get complacent about the risks we are taking. Part of that is because it requires a large number of factors to align before an incident occurs – using CRM, Situational Awareness and Checklists will mitigate some of those risks but they cannot completely remove them.  Use a checklist every dive, use a challenge and response technique with your buddy and pick them up if they make a mistake. If you don’t pick it up, it will become the norm.

There is no such thing as a stupid question, apart from the one you wish you asked just before it all went wrong and you could have prevented it from happening…You can call a dive at any time for any reason. If your buddy complains about it, chose another buddy the next time!

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