I have been asked several times what the PhD work I am doing is all about. There are a number of key studies and these are detailed below.
The aim of this 5 year self-funded part-time PhD is to develop a taxonomy which can be used to classify ‘why’ a diving incident occurs, rather than detailing ‘what’ happened using the Human Factors Analysis and Classification System (HFACS) as the basis for the taxonomy development. The original scope of the study was down-sized for a number of reasons, not least because of the lack of access to raw or anonymised incident data from the BSAC incident database.
The following is the Executive Summary for my 15 month PhD review and covers most aspects.
SCUBA diving is a recreational sporting activity which carries an additional level of risk due to the non-‐life sustaining environment in which it is conducted. Over the last 10 years there have been a mean of 16.45 deaths per year (SD 4.30, Min 10, Max 24) in the UK, equating to an approximate mean annual fatality rate of 1:140 000 (SD 1:36 100, Min 1:89 500, Max 1:213 000) dives. The majority of the incident reporting and research has focused on ‘what’ happened in the incident e.g. out of breathing gas, rather than ‘why’ the incident occurred. There is a significant body of anecdotal evidence to show that many of the reasons for incidents are due to divers not following or violating the ‘rules’ of ‘best practice’. The problem is further compounded because each agency teaches a slightly different way of doing things and diving equipment operation is different, sometimes unique, therefore an agreement of the ‘rules’ is difficult.
Simple causality attributions exist within reports such as the British Sub Aqua Club Annual Incident Report or Divers Alert Network Annual Incident Reports but there is no model which allows causality, and the ‘safety barriers’ that are breached, to be defined and categorised. Denoble et al (2007) conducted a comprehensive study looking at Triggers, Agents and Cause of Death but this did not answer the ‘why’ question.
Using experiences and knowledge from environments with established safety cultures such as aviation, medicine and construction, it is proposed that a systems-‐based causality model, using the Human Factors Analysis Classification System as a baseline, is developed and deployed. This model needs to include the barriers, as conceptually identified by Reason, which prevent minor incidents from developing into major ones or fatalities and, importantly, the reasons for their compromise.
The studies are being conducted through the School of Engineering, Cranfield University under the supervision of Dr Sarah Fletcher who was the lead author/project manager for the HSE Assessment Manual and Emergency Operating Procedures on CCR Report in 2011.