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.
Read full report below.http://www.cognitas.org.uk/disrc-resources/Reference/Cognitas/Human_Factors_in_Sport_Diving_Incidents.pdf