The Birth, Development and Growth of an Incident Reporting System


The Birth
In 2007 I read a paper on the Human Factors Analysis and Classification System (HFACS) and wondered why something like this had not been applied to recreational diving. Over the next few years I worked with individuals within the diving industry to develop a reporting system which would allow detailed analysis of meta-data to take place, but more importantly would provide a dynamic reporting system that would be updated as more data for an incident became available. Something that could use the power of online search tools, rather than search flat documents which were issued once a year and were not publicly updated.

This is where the idea of the Diving Incident and Safety Management System (DISMS) came from. An online, dynamic database that would have an online portal as the means for both report submission and data retrieval. It took six months working with a couple of software and database development teams, Diamond Software Solutions and Sarsen Software, to develop the database backend in SQL and the User Interface in Ruby Rails.  This is the product which was launched on 31 March 2012 at the London International Dive Show.

The Development
Since then more than 100 reports have been entered into the database and on 22 April 14 the first annual report will be published, covering the period 31 Mar 12 up to 31 December. Future reports will run from 1 January to 31 December. These reports provide a quick summary, but the main interaction of the system should be through the online web interface.

DISMS was developed independently of all of the training agencies so that it can be promoted and used by divers irrespective of their agency affiliation or beliefs.  Data from a survey managed by Cognitas in 2012 showed that two of the major reasons for divers not submitting reports to BSAC and their Incident Reporting system was because they were not members of BSAC, or did not know about the reporting system.   Hopefully by being independent, there will be an increase in uptake so that more divers can learn from the mistakes that we make, irrespective of experience, knowledge, skills or standing in the community.

The database was designed such that tags could be allocated to diving incidents, which in addition to the keyword search, would allow incident categories or environments to be quickly searched for. The following tags can be searched for:

OC, CCR, Cave, Overhead, DCI, Medical Issue, Hypercapnia, Hyperoxia, Hypoxia, Entanglement, Equipment, OOG, Separation.

Making mistakes knows no boundary when it comes to agency affiliation or training , and neither does learning from them.

The Future
One of the aims of my PhD research is to develop and deploy an incident causality model which can be used to compare disparate datasets by allocating tags created from the HFACS-D model to incidents, these tags will specifically focus on the role of Human Factors and will cover individual level and organisational/supervisory level factors.  Once this research has been validated, the tags will be deployed into DISMS.

A future aspiration is to import datasets from other organisations, publications or fora such that the datasets can be searched in one location. The use of tags will allow targeted searches to be carried out against a number of different incident reports.

Interest in DISMS is not just limited to the UK diving community, and three organisations external to the UK have expressed an interest in using DISMS as the basis for their own incident reporting system.  By using a common model, it might be possible to share data at the meta-data level without compromising the confidentiality of the specific data captured.


DISMS costs money to run, approximately £1000 per year. Developing DISMS further will add to those costs although the ability to use tags is already built-in so a major capability will cost nothing but time to enter the tags against each incident! If you are interested in supporting the running costs of DISMS please visit this page.

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