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Diver Community Support Required – Diver Incident and Safety Management System (DISMS)
In 2007 I read a paper on Human Factors Analysis and Classification System (HFACS) and my interest in improving diver and diving safety was piqued. (HFCAS was initially developed as a way of identifying the root causes of aviation accidents). As RAF aircrew (operator, supervisor and instructor) and a diver I could see how Human Factors Analysis processes and procedures from aviation could be applied to sport diving, especially looking at back at some of the risks I took because I was unaware of the consequences or probabilities. Five years on and I’ve started a PhD in Human Factors in Sport Diving Incidents at the School of Engineering, Cranfield University. This will provide more focus and rigour to the work I am already doing. My supervisor, Dr Steve Jarvis, is one of the co-authors of the HSE report (released in May 2011) on Human Factors and CCR incidents and safety.

This post is in 2 parts; a quick summary for those know about the work I have been doing or don’t want to read too much, then a longer section below for those who aren’t aware or who are interested in the detail.

Quick and Dirty:

In September 2010, I presented to the British Diving Safety Group (BDSG) the need for an agency independent and more open system could result in greater reporting and therefore more accurate data for analysis by a broader group of experts, especially within the technical diving domain. After 18 months of discussions with the UK technical diving agencies (GUE, IANTD and TDI), the User Interface (UI) for an improved reporting system is close to being finally developed. Improvements can be made because it is recognised that not all incidents and even some fatalities, for a variety of reasons, are not being captured by the BSAC Incident Reporting System. For example, there are 3.5x as many DCI treatments as reported through the BSAC system (2009 figures) *. Identifying incidents and their causalities allows individuals to understand the risks they are taking and training organisations to modify courses and emphasis. In both counts this will potentially save lives by modifying diver behaviours. Those concerned about data fragmentation will be pleased to know that Diving Incident and Safety Management System (DISMS) reports can be exported in a BSAC Incident Report form format, if required.

*I had previously stated that BSAC had missed one fatality in their annual report. This was based on an erroneous assessment following knowledge that I had gained from a reported incident that did not appear on the BSAC Fatality register.  However, this incident was indeed captured and was reported in the Annual Incident report.  Apologies for any confusion caused by this error.

However, to make sure that the system is as easy to use as possible, both from an incident reporter and a data retriever point of view, the web based development is being professionally developed; it will take around 20 man-days and 6 weeks real-time to complete. This UI will make significant improvements to the data entry pages allowing OC, CCR & SCR options, login details, data security and field formatting (both input and output) as well as a host of other usability improvements. This is not an insignificant task and the quote for the development is £4000. Four thousand pounds might seem a lot, but spread out amongst the diving community, it isn’t much; simply £50 from 80 people or organisations would cover the development and deployment costs. Annual running costs are in the order of £750. There have already been pledges from leading instructors, academics and organisations, but it isn’t enough. The technical training agencies are interested but don’t want to commit too much money either. If you have a look at this presentation (link removed as DISMS is now live here).

If you want to support this development, you can either use Paypal (paypal@cognitas.org.uk) or contact me for bank details. General feedback and ideas are also appreciated. The contact address is feedback@cognitas.org.uk.

The Longer Version

In May 2010 I conducted a survey looking at ways to improve diver incident reporting (some of you may remember this) and subsequently published a report which went to the British Diving Safety Group in Sep 2010 (http://www.cognitas.org.uk/cognitas/Report.html); this report was attitudinally biased and drove towards a specific solution rather being truly independent. Whilst the BDSG as a whole generally felt that the status quo works (BSAC Annual Diving Incident Report – http://www.bsac.com/page.asp?section=1038&sectionTitle=Annual+Diving+Incident+Report), the technical agencies represented at the BDSG (GUE, IANTD and TDI) appreciated it would be useful to define the requirements for an open and transparent reporting system. Identifying incidents and their causalities allows individuals to understand the risks they are taking and training organisations to modify courses and emphasis. In both counts this will potentially save lives by modifying diver behaviours.

In mid-2011, I worked with a database specialist (Diamond Software Solutions) to understand how a backend database could be developed which would allow a wide range of datasets to be stored securely but would also provide transparent reporting available to the whole diving community, from beginners all the way to agency training staff. Whilst the back-end was ‘relatively’ easy to define, the web User Interface (UI) which would be required to make data capture easy and quick was beyond the capabilities of myself and the database designer. So, in late 2011 I held a meeting with Sarsen software (http://sarsen.biz/) to look at what was required. Sarsen have been dealing with reporting and data capture for some time and because one of the partners is a technical diver, they decided to waive their management overhead fee but that still meant that £4000 would be required to develop the UI. The UI will take approximately 6 weeks of realtime work which will include user feedback from myself, Sarsen and the training staff of the technical agencies. £4000 might seem like a lot, but for a project which would benefit the wider diving community, it could be simplified as £50 per head from 80 people or organisations. I have already had pledged support from leading academics, some of the top training staff in the UK and inland diving sites. Unfortunately, despite my considerable personal investment in Cognitas Incident Research and Management (http://www.cognitas.org.uk/), my own personal investment in this will not stretch to £4000 and I am now looking to the wider diving community to support this project.

There will be longer term support costs, which will be in the region of £750 per year, which will also require funding and this will cover ongoing software development/updates, domain & email registration and hosting, ICO registration etc. Part of this can be funded by me, but again there will be a need to support this. I am hoping that once the benefits and outputs have been demonstrated, the diver training agencies and diving community will provide a more robust support mechanism.

So, what would you get from supporting this project?

There is more detail in the presentation which I have put together here (link removed as DISMS is now livehere) which will explain what the Diving Incident and Safety Management System (DISMS) is all about. (The presentation is a general idea of how data entry can be made and any fields/entry requirements are there for conceptual purposes; the final version being developed with the agencies training staff, myself and Sarsen.) In essence, supporters will get:

–Be seen to be actively supporting improved diving and diver’s safety and potentially saving lives;
–Show that Diver/Diving Safety is taken seriously by them; and finally,
–They will be listed in section on the DISMS website as a Supporter. (However, if a supporter wishes to stay anonymous, that of course will be honoured)

Making a donation now does not tie you in long-term but without support from the diving community, this capability will not be available.

The DISMS will be independent from all of the training agencies and no agency will have priority over the data extracted; it will be open for all at the same level. This has been one of the prime factors in developing the DISMS, all data which is open will be open for all, allowing users to create ‘custom reports’ using XML, and standard reports generated every quarter. Standard reports for the user also include a BSAC Incident Report format for those who want to send a report to BSAC for inclusion in the Annual Diving Incident Report. I have also been in contact with RoSPA who are looking at ways to promote rebreather safety and are supportive of this project as a means to collect data; both numerical and lessons learned.

There is obviously a concern about data protection and reporter confidentiality. Cognitas recognise that the confidentiality of reporters is essential in allowing such a system to be widely adopted but to allow the maximum benefit to be gained, a useable level of detail is required. As such, there will be an option for the reporter to remain anonymous if they wish, in addition, there will also be an option for a reporter to not be contacted by Cognitas following submission of the report. There are a couple of reasons why Cognitas would want to contact the reporter including when new data is available (e.g. inquest) or to ensure they are happy with the level of anonymity in the report. Cognitas is registered with the Information Officers Commission and all data will be stored in accordance with the Data Protection Act. In addition, to ensure that the data can be used by organisations such as Duke Medical Centre and DAN, I have taken the advice of their senior staff who support this project and will be seeking Institution Review Board (IRB) clearance through Cranfield University before live data entry takes place. (Cranfield has been selected as this is where I will be undertaking my PhD in Human Factors in Sport Diving Incidents.)

I hope to announce at the time of the London International Dive Show (LIDS 2012) that the DISMS is live, ready for the forthcoming dive season, but do not want to commit to work without the financial backing which I need from the diving community.

Whilst I know that many incidents are not reported, and there are wide range of reasons why people don’t report, the technical training agencies in the UK, the academics I have spoken to and I, all believe that providing a reporting system which is independent of all of the training agencies will help alleviate some of the concerns.

If you have any questions or feedback, please do not hesitate to contact me via email (this will be posted on multiple forums, and will be hard to track specific comments if I am not aware of them). My email is feedback@cognitas.org.uk or if you want to speak to me in person, my contact number is on the Cognitas website (http://www.cognitas.org.uk/cognitas/Contact.html).

Follow up post on 29 Jan 12

 Thanks for the comments, feedback and support so far. It is appreciated.

To start with, I have a lot of respect for the work that BSAC have done in this area in the UK.  There is nothing to compare to it in the UK for diving. DAN US and Europe have similar set-ups and the Australians have something completely independent called Project Stickybeak; have a look on the Rubicon for SPUMS and Project Sitckybeak for examples of what can be achieved with data from diving incidents.

Secondly, I know that there are major challenges in what I am trying to achieve. However, what I am trying to do isn’t just about incident reporting, it is about trying to engender a culture where reporting is the norm; where more robust statistics can be derived along with more detailed ‘lessons learned’ that can be provided.  Many of the issues raised concern fatalities and the need to protect families, but there is almost as much to be learned from ‘near-miss’ incidents, the sort of thing posted in ‘I Learned About Diving From That’. In fact, in many cases, there is more to learn as the incident subject is still alive and can tell us what happened.  Research has shown that classification of incidents is sometimes nugatory because of the complex interactions out there.  However, providing feedback on what went wrong, or what someone did to correct a problem, is of massive benefit in providing ‘feedforward’ to prevent an incident from developing further.

What will the DISMS give the diving community?  

 It will be independent from all agencies and manufacturers which means it is easier for any agency to recommend reporting to and to include that in their training materials. (This is why I have been engaging with the training directors of the main UK technical agencies and they are onside with an independent system). It will also mean that those who don’t want to report to BSAC, for whatever reason, have somewhere to report.

It will provide an output to academic research which allows the allocation of incidents to be transparent and searches/filters to be conducted without going through the data owner (this is explained in more detail below).

It will be open which means that reports and data (within limits) will be available to all. However, open data doesn’t mean compromised confidentiality.  Have a look at CHIRP (http://www.chirp.co.uk/feedback-list.asp?fb=GA), IMCA Safety Flashes (http://www.imca-int.com/documents/core/sel/safetyflash/) and NASA ASRS (http://akama.arc.nasa.gov/ASRSDBOnline/QueryWizard_Filter.aspx) All of these are confidential reports but the outputs are open and, in some cases, detailed. The ASRS allows a filtering process to allow you to drill down or ask for specific search criteria. This is the sort of output that will be enabled within the DISMS. Certain fields in the database will be accessible to admins only (vetted and none with a commercial interest in diver training or equipment manufacture), a reduced dataset available to subject matter experts (again vetted and similar to the board at CHIRP http://www.chirp.co.uk/people-people.asp?board=GA to provide expert advice) and a further reduced dataset available to everyone who can generate reports as they wish (along the lines of the ASRS).  Each field entered into the database will have a ‘permissions‘ attribute which will determine the visibility of data. I have taken advice about how to construct the datasets to ensure that this is dealt with.  It should be noted that there is a difference between an anonymous system and a confidential system; an anonymous system will contain unidentifiable reports, whereas a confidential system allows contact details to be entered so that clarification can be sought.  In both cases data will be kept safely, but the level of detail is likely to vary.

By providing good quality reports as exemplars, then the quality of the initial submission will be improved and so less work will be required in ensuring that data collected is correct.  Those reports which I have been collecting so far and uploading to the DISRC with the reporter’s permission, have followed a template which allows the reporter to think about areas which should be covered.

Regarding picking up the pieces if this fails. If those who aren’t using the BSAC system (for whatever reason) subsequently use DISMS to report incidents and then it collapses, are they lost data ‘subjects’ to BSAC? On the other-hand, those who are using the current BSAC system then use DISMS to allow ‘duplication’ of data because it ‘kills 2 birds with one stone’ by providing data to DISMS and BSAC at the same time, and DISMS collapses, is that a lost ‘reporter’ too? Consequently having an independent, open system is a win-win situation because reports will be captured which otherwise wouldn’t have been.

Finally, the main theme that comes from many sources is that you need to improve reporting culture to be able to collect more data. However, before we can do that, we need to understand why people aren’t reporting and address those issues.  My limited surveying and feedback from presentations is that some of those people who don’t report would report if they had an independent system to report to which they thought would provide more open reports.  Providing something that is independent but can still be used by the existing system for stats has got to be a good thing.

I am sure there will be more questions but hopefully this will address some of the concerns raised in previous posts.

To end, I’d like to include a quote from the DFW in 2010 from the Legal Issues Associated with Scuba Diving Fatalities panel (http://www.davidconcannon.com/publications/scubadivingfatalities.html). “Finally, one questioner remarked that some divers seem to think it is their Constitutional right to go diving, regardless of their health and other limitations, and there was little that could be done to keep some people from becoming statistics.  The panel members universally agreed that this was a problem and, as David Concannon remarked, “Sometimes you can lead a horse to water, but you have to put the right end in the trough.”  Generally, the panel members emphasised adherence to industry standards, awareness of the risks associated with diving and acceptance of personal responsibility, as the best way to avoid scuba diving fatalities.” – those who are going to ‘violate’ best practices are going to do so no matter what you show them, but the vast majority of divers would like to know how to solve problems, or prevent an incident from occurring in the first place. A more open and detailed reporting system will provide that – like ILADFT on The Dive Forum allows divers to see how others solved (or didn’t) problems or issues and then apply them to their own diving.

Please keep providing me feedback and comments; they are very much welcome.

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