“Diver Error”…Is it a Cop Out?

Reason-HumanErrorThe printed and online press is full of ‘Pilot Error’ comments when a plane crashes or has an accident, ‘driver error’ for train crashes or ‘XXX error’ when another operator is involved in something going wrong.

When we see the press or analysis regarding diving accidents, invariably the term ‘diver error’ is used too. Unfortunately this isn’t a very useful term because the term ‘error’ in the context of accident or incident causality is simplistic and covers a number of specific areas.

James Reason, considered one the leading individuals in this field, published a seminal work in 1990 entitled ‘Human Error‘ which examined the different types of errors which can occur at the individual level.

These different types of errors were defined as slips, lapses, mistakes and violations.  Simplistically they are explained as:

  • Slips – Correct intention, wrong execution (Attention Failure).
  • Lapses – Correct intention, but forgot to execute it (Memory Failure).
  • Mistake – Intentionally carried out wrong action (Intention Failure)
  • Violations – Breaking ‘rules’ or ‘norms’ of the system, the reasons and context for which define the type of violation.
To improve safety, by improving outputs given the limitations and risks of the systems and managing them to an acceptable level, we need to understand why the system failed, not just what the failure mode was.  There is enough evidence to show that if you run out of gas at depth and have no alternative, you will either drown, or have a rapid ascent linked injury such as CAGE or DCI.

The ‘why’ can be simply defined as didn’t monitor gas consumption/gas remaining, or didn’t notice massive gas leak. But that doesn’t necessarily help because it will not change or influence behaviours to improve safety. Telling someone to monitor their gas on a dive is like saying ‘drive safely to work’, or be careful with that chainsaw. People don’t drive to work with the intention of having an accident, or plan to sever a limb with a chainsaw – no different than divers going diving with no plan to monitor their gas until the end of their planned bottom time or until the regulator goes tight in their mouth.

So, when you hear ‘Diver Error’ in any analysis have a think through what the reasons for the error might be. Only by considering this do we have any chance of reducing incidents by influencing yours or others’ future behaviours.  Furthermore, when you complete an incident report (such as at DISMS – www.divingincidents.org) think through why the incident developed in the way it did, and what slips, lapse, mistakes or violations contributed to it reaching the level it did. Then commit those to paper so others can understand WHY the slip, lapse, mistake or violation occurred.

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