There have been many studies looking at fatalities in sport diving, and in the main what the causal factors are, but none have looked at the influence of human factors to understand ‘why’ incidents occurred. In 1997, a team who had developed the Human Factors Analysis and Classification System (HFACS) used it to examine a large number of US Navy and Marine Corps aviation accidents between 1991 and 1997 to understand why accidents were happening and whether pilot error or violations of rules were to blame. The study concluded that roughly a third of accidents were down to the violation of rules. Through studying these accidents, their casual factors, and the application of the HFACS, naval aviation flight safety was improved and the number of accidents reduced.
This paper takes the processes and procedures from the HFACS and applies them to incident and accident analysis with a view to improving diver safety. The paper looks at the four layers of an incident proposed by James Reason; unsafe acts, pre-condition for unsafe acts, unsafe supervision and organisational failures. These layers are then further broken down into sub-components detailing examples and mitigations.
This paper highlights that the diver, the supervisor or instructor, and the organisation or training agency each have their own level of responsibility in the prevention of incidents and accidents. Whilst individuals can drive a positive attitude upwards, there is a need for organisations to promote a culture that ensures that divers continue to follow the recommendations and procedures promoted and taught by training agencies, even years after a training course has finished; as in aviation, most incidents have their roots in violations of procedures and recommendations.
One such positive area is the introduction of a ‘Just Culture’, which encourages divers and instructors to report incidents or failures without fear of retribution or criticism; introducing such a culture in military and civil aviation, Air Traffic Control and medical environments has led to a marked reduction in accidents and incidents.
Sport diving by its definition is a sport and hobby, and therefore traditional supervision does not take place in the majority of diving activities. However, peer review of diving activities does occur and encouraging an attitude whereby divers can comment constructively and provide feedback on their peer’s unsafe operations is needed. Addressing and encouraging this Just Culture and the application of the HFACS to diving incidents and accidents should be a high priority of the diving community at all levels; individual, supervisor and organisational levels.
This area of work makes up the majority of the first section of my PhD
The report can be downloaded here Human Factors in Sport Diving Incidents
“A great start on research examining other causative or contributing factors in diving accidents. This needs much more attention and the paper by Gareth Lock will hopefully open the door for more contributions and research. Brace yourself there are terms Americans hate to hear in this one – like responsibility – even worse personal responsibility! I am aghast!! Thank you for sharing Gareth”
– Mike Ange, SEAduction on the Human Factors paper.
“It is so refreshing to see someone taking this approach towards diving accident analysis. Kudos to you for taking the initiative and combining two fields where your expertise overlaps on so many levels.”
– Dawn Kernagis, Duke Medical Centre for Hyperbaric Medicine on the Human Factors paper
“The whole concept of swiss cheese is very powerful because it is so visual (mathematically it’s like conditional probability!) and clearly shows that the ‘diver error’ at the end of the chain, which is so often is put forward as the cause of an incident, is just that…at the end of the chain.”
– Elisabeth Rackham on the Human Factors paper
Cognitas Incident Research & Management 