As part of my ongoing research, I have been trying to categorise a number of factors, errors and mistakes into one of the sections within the Human Factors Analysis and Classification System (a first stab is here) model. It has been quite challenging because they are so context dependent – was the diver trained to start with, did they forget, did they chose to ignore their training…the list goes on. So, in the end there will be a section that says violations will be defined as the intent to conduct the activity which lead to the mistake or error. This flow diagram from the Royal Navy (1) shows what I mean by this.
Now the problem faced when looking at the model to determine whether there was an error or a violation is that there are very few ‘rules’ in the system and in the majority of cases, there is only guidance.
Today I completed a class to requalify my GUE Technical Diver 2 Open Circuit Advanced Trimix certification as I had not completed enough dives in the last few years to maintain it. The class also allowed me to get an update on the current SOPs from GUE including ascent rates, stop depths, gas planning methodologies. This document is a live publication available from here which details in a certain live of detail what divers should do and shouldn’t do, covering all the drills and skills expected of them. The primary purpose is to show divers what the correct method of doing something is if they have forgotten – a reference document. One of the major strengths of GUE is the global standardisation where a diver can travel around the world and with minimal pre-dive checks, discussions etc, ‘shake hands, and go diving’ because they know what the protocols are, and they know that they have all been trained to the same standard (SOP) by an instructor of consistent standard.
The secondary benefit is as part of a Just Culture by providing a means of identifying to someone who has done something wrong (with or without knowing, violation or error/mistake) and what the correct action/drill/skill is or should have been.
It is very hard to go up to someone on a boat and ask why they are doing something which you perceive to be wrong or dangerous, when you don’t know their background so it might be what they are taught or may have been taught incorrectly, or that isn’t what their agency believes is correct – having an SOP makes things so much easier.
Something that I hadn’t realised until today, but there is also a public feedback mechanism to GUE HQ through a Request Force Change (RFC) on the GUE website, so if you think something needs to be addressed in the SOP, use this link. From discussions today, it appears that there have been some changes instigated following feedback from me – at least the system works!
Not every agency has an SOP because they believe in the freedom of choice when it comes to delivering training, but a publicly available SOP certain helps when it comes to identifying problems in the field and also what should or shouldn’t be taught/undertaken. When the line is drawn in the sand, you know when you have crossed it.
(1) Royal Navy, 2012, A GUIDE TO UNDERSTANDING HUMAN FACTORS & HUMAN BEHAVIOUR In Safety Management & Accident Investigation, Fleet Graphics Centre, Royal Navy, London