culture. isn’t just something that grows in the lab (or kitchen)
TRANSCRIPT
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Culture. Isnt just something that grows in the lab (or kitchen)...
Improving Diving Safety Through Improved Reporting and a Just Culture
Gareth Lock E: [email protected] M: 07966 483832
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Scope Risk Cultures What is an Incident? Reporting, why should I? Case Studies Reporting Opportunities DISMS Conclusions
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Introduction
Full time RAF Officer (ex C-130 aircrew)
Adv Trimix Diver Studying for PhD
Cranfield
Cognitas in 2010 DISMS launched Apr 2012
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Risk, What is It?
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Risk, What is It? What is risk?
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Risk, What is It? What is risk?
Probability x Impact
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Risk, What is It? What is risk?
Probability x Impact Acceptable level based on
Experience, Attitude, Training and Culture...
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Risk, What is It? What is risk?
Probability x Impact Acceptable level based on
Experience, Attitude, Training and Culture...
Relative
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Risk, What is It?
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Risk, What is It? What is risk?
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Risk, What is It? What is risk?
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Risk, What is It?
Diving is risky What is risk?
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Risk, What is It?
Diving is risky Baselines are required
What is risk?
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Risk, What is It?
Diving is risky Baselines are required Understand the risks
What is risk?
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Risk, What is It?
Diving is risky Baselines are required Understand the risks
Educate but dont scare
What is risk?
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Risk, What is It?
Diving is risky Baselines are required Understand the risks
Educate but dont scare Mitigate and reduce them
What is risk?
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Risk, What is It?
Diving is risky Baselines are required Understand the risks
Educate but dont scare Mitigate and reduce them
To improve safety, not primarily reduce litigation
What is risk?
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Risk, What is It?
Incident
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Risk, What is It?
zIncident
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Safety Margin
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Risk, What is It?
zIncident
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Human Error!(Active/Latent)
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Risk, What is It?
zResources
Incident
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Human Error!(Active/Latent)
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Risk, What is It?
zResources
IncidentBad Luck!
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Human Error!(Active/Latent)
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Risk, What is It?
zResources
IncidentBad Luck!
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Human Error!(Active/Latent)
Training
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Risk, What is It?
zResources
IncidentBad Luck!
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Human Error!(Active/Latent)
Training
Feedback
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Risk, What is It?
zResources
IncidentBad Luck!
Safe Limit for Recreational
Diving
Safe Limit for Technical!
Diving
Human Error!(Active/Latent)
Training
ReportingFeedback
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Cultures
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Cultures What are they?
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Cultures What are they?
Culture can be described as the shared values and beliefs within an organization which create
behavioural norms (Shaw and Blewitt, 1996)
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Cultures What are they?
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Cultures What are they?
Common Beliefs Common Goals Common Behaviours
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Cultures
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Cultures Safety Culture
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Cultures Safety Culture
Reporting Culture Just Culture Informed Culture Learning Culture Flexible Culture
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Safety Culture
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Reporting Culture
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Reporting Culture Linked to Just Culture Survey initiated as part of PhD
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Reporting Culture Survey
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Reporting Culture Survey
Percentage of Divers Had Incidents?
Types of Incidents Knowledge of the BSAC
system
Reasons for not reporting DCI Occur vs Report
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Survey: OC/Tech/CCR/All
Rec,%72.41%%Tech,%38.07%%
CCR,%8.28%%All,%10.90%%
OC#Rec,#OC#Tech,#CCR#or#All#
Rec%
Tech%
CCR%
All%
The diving profile of all 725 UK respondents
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Survey: Age
0.0%$
4.6%$
7.2%$
16.0%$
18.1%$19.8%$
14.0%$
11.5%$
8.6%$
0.3%$0.0%$
5.0%$
10.0%$
15.0%$
20.0%$
25.0%$
Under$16$
16325
$
26330
$
31335
$
36340
$
41345
$
46350
$
51355
$55+$
Not$Listed$
Tech/CCR:)Age)of)Respondents)
Tech/CCR:$Age$of$Respondents$
Nearly 54% respondents are over 40 yrs age, 57% within total community, 59% Rec only
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Survey: Had An Incident?
Yes,%80%%
No,%17%%
No%Answer,%2%%
Ever%Had%An%Incident%Yes/No?%All%Divers%OOA,%Separa;on>Solo%Ascent,%UBA,%DCI%
Yes%
No%
No%Answer%
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Survey: Knowledge of BSAC Reporting (Tech & CCR)
No#ANSWER,#2.3%#
Know#Nothing,#16.9%#
Heard#About#it,#23.2%#
Occasional,#30.9%#
Every#Year,#18.8%#
Every#Year/Report,#6.3%#
Tech%(OC%&%CCR).%Non0BSAC.%%Knowledge%of%BSAC%Incident%Repor?ng%System%
No#ANSWER#
Know#Nothing#
Heard#About#it#
Occasional#
Every#Year#
Every#Year/Report#
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Survey: Knowledge of BSAC Reporting (Rec)
No#ANSWER,#1.3%#
Know#Nothing,#37.6%#
Heard#About#it,#33.8%#
Occasional,#18.5%#
Every#Year,#8.9%# Every#Year/Report,#0.0%#
Rec$Only.$Non,BSAC.$$Knowledge$of$Incident$Repor;ng$System$
No#ANSWER#
Know#Nothing#
Heard#About#it#
Occasional#
Every#Year#
Every#Year/Report#
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Survey: Reasons for Not Reporting - All Divers
27% Not BSAC Member. 34% Trivial/Not Serious
Didn't'Know'About'BSAC'Annual'
Incident'Report'11%'
Not'BSAC'Member'20%'
Didn't'Know'How'To/Should'Do'5%'
Apathy/Laziness'5%'
Resolved'before/aKer'Surfacing'4%'
Unlikely'to'Contribute'to'Learning/Trivia/Not'Serious'
23%'
Report'to'PADI/SAA/DISMS/Other'Agency'
3%'
Lack'of'Trust/Belief'in'Current'System'
5%'
Lack'of'Clarity'of''Incident''9%'
Overseas'Incident'5%'
Completed'by'Someone'else'4%'
Lack'of'Time/Forgot'4%'
Embarrassment/Personal'Feelings'
1%' Incident'Happened'to'Someone'Else'
1%'
Reasons'for'Not'Repor-ng'(n=419)'
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DCI vs Reporting
2010 BSAC Figures: 105 2010 BHA Chamber Recompressions ~350 DDRC Study 2002 - ~45% self diagnosed
DCI didnt reported to chamber
2012 Reporting Survey Tech Only (#349), DCI Yes - ~25% All Instructors, DCI, not chamber - ~10%
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Reporting Culture
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Reporting Culture Improvements are
needed
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Reporting Culture Improvements are
needed Guidelines on what is an
Incident
Independence may improve uptake
Easy to submit report Useful outputs Promotion of Reporting
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Reporting Culture Improvements are
needed
Govaarts C. EAM 2/GUI 6 - Establishment of Just Culture Principles in ATM Safety Data Reporting and Assessment. Safety Regulation Unit, EUROCONTROL; 2006.
Guidelines on what is an Incident
Independence may improve uptake
Easy to submit report Useful outputs Promotion of Reporting
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Just Culture
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Just Culture Not no blame
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Just Culture Not no blame
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Just Culture Not no blame The environment to talk about or
report an incident without fear of retribution (professional/peer)
Consoling the human error Coaching the at-risk behaviour Punishing the reckless behaviour
Not no blame
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Just Culture Not no blame The environment to talk about or
report an incident without fear of retribution (professional/peer)
Consoling the human error Coaching the at-risk behaviour Punishing the reckless behaviour
Who draws the line...?
Not no blame
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What is an Incident?
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What is an Incident?National Research Council defines a safety incident as an event that, under slightly different circumstances, could have been an accident.National Research Council, Assembly of Engineering, Committee on Flight Airworthiness Certification Procedures. Improving aircraft safety: FAA certification of commercial passenger aircraft. Washington, DC: National Academy of Sciences, 1980.
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What is an Incident?National Research Council defines a safety incident as an event that, under slightly different circumstances, could have been an accident.National Research Council, Assembly of Engineering, Committee on Flight Airworthiness Certification Procedures. Improving aircraft safety: FAA certification of commercial passenger aircraft. Washington, DC: National Academy of Sciences, 1980.
We defined a near miss as any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome. Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ 2000, Mar 18;320(7237):759-63.
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What is an Incident?
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What is an Incident? Unplanned separation at depth, solo ascent
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox CO2 hit
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox CO2 hit DCI end in paralysis
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What is an Incident? Unplanned separation at depth, solo ascent OOG back gas just before end of BT Twin indies, end dive 20bar/210bar Major (N2 or CO2) Narcosis Event DCI, no lasting effects once on O2 on boat CCR failure at end of BT, bailout ascent OxTox CO2 hit DCI end in paralysis Fatality
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What is an Incident?
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What is an Incident? 10% Lack of Clarity
More guidance required
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What is an Incident? 10% Lack of Clarity
More guidance required 34% Trivial/Not Serious/Not
Contribute to Learning
Why do we still make same mistakes?
Not perceived as relevant to my deep gas diving. - referring to BSAC AIR
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Case Study One MCCR Shutdown
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Experienced Trimix Instructor, Relatively New CCR Diver
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Experienced Trimix Instructor, Relatively New CCR Diver
Forgetting O2 shutdown post dive
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Experienced Trimix Instructor, Relatively New CCR Diver
Forgetting O2 shutdown post dive
Shutdown O2 progressed from dekitting to on lift
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Experienced Trimix Instructor, Relatively New CCR Diver
Forgetting O2 shutdown post dive
Shutdown O2 progressed from dekitting to on lift
Shutdown in water waiting for previous diver/lift
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Experienced Trimix Instructor, Relatively New CCR Diver
Forgetting O2 shutdown post dive
Shutdown O2 progressed from dekitting to on lift
Shutdown in water waiting for previous diver/lift
PPO2 0.07 on lift Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Reported: Diver shutdown O2 in water. Broke rules.
Image from www.kissrebreathers.com
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Case Study One MCCR Shutdown
Reported: Diver shutdown O2 in water. Broke rules.
Not one reason for incident, back story possible to understand WHY
Image from www.kissrebreathers.com
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Case Study Two CCR Narcosis
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Case Study Two CCR Narcosis
Experienced MOD 3 level CCR Diver
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Case Study Two CCR Narcosis
Experienced MOD 3 level CCR Diver
Stressful previous days
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Case Study Two CCR Narcosis
Experienced MOD 3 level CCR Diver
Stressful previous days Issues on descent, carried
on despite ascending to clear
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Case Study Two CCR Narcosis
Experienced MOD 3 level CCR Diver
Stressful previous days Issues on descent, carried
on despite ascending to clear
CO2/N2 Narcosis and bailed out, then problems started!
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Case Study Two CCR Narcosis
Experienced MOD 3 level CCR Diver
Stressful previous days Issues on descent, carried
on despite ascending to clear
CO2/N2 Narcosis and bailed out, then problems started!
Fortunately resolved at 21m on OC bailout after 20mins
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Case Study Two CCR Narcosis
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Case Study Two CCR Narcosis
Likely Reported: Potential narcosis leading to bailout
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Case Study Two CCR Narcosis
Likely Reported: Potential narcosis leading to bailout
Not one reason. Many opportunities to stop incident developing. Full story required to understand WHY
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Reporting, Why Should I?
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Reporting, Why Should I? What is the Risk?
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Reporting, Why Should I? What is the Risk? How Big Is the Problem?
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Reporting, Why Should I? What is the Risk? How Big Is the Problem? Where is the Problem?
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Reporting, Why Should I? What is the Risk? How Big Is the Problem? Where is the Problem? Reasons Swiss Cheese Model
Organisational Influence Unsafe Supervision Pre-Condition for Unsafe Acts Unsafe Acts
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Reporting, Why Should I? What is the Risk? How Big Is the Problem? Where is the Problem? Reasons Swiss Cheese Model
Organisational Influence Unsafe Supervision Pre-Condition for Unsafe Acts Unsafe Acts
How To Stop It Happening Again?
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Consumers of Reports
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Consumers of Reports Type I
Professionals Scientists/Researchers Duty of Care/
Organisation Staff
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Consumers of Reports Type I
Professionals Scientists/Researchers Duty of Care/
Organisation Staff
Type II Fun Divers
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Reasonss Swiss Cheese Model
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Reasonss Swiss Cheese Model
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Reporting, Why Should I?
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Reporting, Why Should I? Data Provision
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Reporting, Why Should I? Data Provision
Safety conferences, lack of data
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Reporting, Why Should I? Data Provision
Safety conferences, lack of data Insurance and financial implication
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Reporting, Why Should I? Data Provision
Safety conferences, lack of data Insurance and financial implication
Lessons Learned
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Reporting, Why Should I? Data Provision
Safety conferences, lack of data Insurance and financial implication
Lessons Learned Needed to support Just and Reporting
Cultures - Feedback loop
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Reporting, Why Should I? Data Provision
Safety conferences, lack of data Insurance and financial implication
Lessons Learned Needed to support Just and Reporting
Cultures - Feedback loop
Consistently similar problems or errors, likely to be an organisational or supervisory problem - Reason
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Reporting Opportunities
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Reporting Opportunities Online Forums
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Reporting Opportunities Online Forums Training Agency Reporting
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Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting
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Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting DAN
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Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting DAN BSAC
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Reporting Opportunities Online Forums Training Agency Reporting Manufacturer Reporting DAN BSAC DISMS
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DISMSDiving Incident and Safety Management
System
http://www.divingincidents.org
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DISMS
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DISMS Open
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DISMS Open Confidential
User Defined level of disclosure
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DISMS Open Confidential
User Defined level of disclosure Live database
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DISMS Open Confidential
User Defined level of disclosure Live database Online, secure web-based (+mobile)
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DISMS Open Confidential
User Defined level of disclosure Live database Online, secure web-based (+mobile) Independent
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DISMS Open Confidential
User Defined level of disclosure Live database Online, secure web-based (+mobile) Independent User conductible searches/exports
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Demo of DISMS
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Demo of DISMS
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Areas for Improvement
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Areas for Improvement More Analysis Needed in Reports
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Areas for Improvement More Analysis Needed in Reports Increase number of filter options
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Areas for Improvement More Analysis Needed in Reports Increase number of filter options Improve drop down options esp CCR
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Areas for Improvement More Analysis Needed in Reports Increase number of filter options Improve drop down options esp CCR Greater uptake from the user
community
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Summary
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Summary More opportunity for Lessons Learned
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Summary More opportunity for Lessons Learned
Easier to address than total stats capture, probably greater impact too
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Summary More opportunity for Lessons Learned
Easier to address than total stats capture, probably greater impact too
Needs stronger Reporting Culture
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Summary More opportunity for Lessons Learned
Easier to address than total stats capture, probably greater impact too
Needs stronger Reporting Culture But Just Culture essential to improve
reporting
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Summary More opportunity for Lessons Learned
Easier to address than total stats capture, probably greater impact too
Needs stronger Reporting Culture But Just Culture essential to improve
reporting
DISMS provides open, confidential and independent reporting system
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Questions?
From a safety perspective, it is not criminal to make an error, but it is
inexcusable if you dont learn from it - Wiegmann/Shappell 2003
www.cognitas.org.uk http://www.divingincidents.org