Tilting at Windmills: Limitations of the professional aviation safety model in sport diving

In 1985 I joined the Navy. After a 14 week stint at Aviation Officer Candidate School (“An Officer and a Gentleman”), I began pilot training.

Military life was a different world in all sorts of ways (I still fold my “skivvies” in a 6” X 6” square, but at least I no longer iron them), and the changes in routine ranged from confusing, to frustrating, and occasionally even to the welcome.

Naval Aviation’s attitude toward safety fell into the welcome category, and it was immediately apparent to me that sport diving could benefit from some of the lessons learned operating from the carrier deck.

But, as the saying goes, “The devil is in the details,” and I had to wonder which aspects of Naval Aviation’s methodical “systems” approach to safety were transferrable to sport diving, and which were not. What appeared at first glance as an easy task in 1985 became more complex with each passing year.

Naval Aviation’s safety program permeates every aspect of both training and actual operations; it is not open to negotiation. In contrast, it was clear to me that for practical purposes a single, cohesive “dive community” did not even exist.

Each dive certification agency at the time (and maybe still?) was in active competition for new students, there was little standardization, and recreational divers lacked a common goal or purpose.

Because the Navy’s rapid training cycle did not allow for the accumulation of significant experience (experience being the single greatest contributing factor to proficiency, in my opinion) prior to operational deployment, the training system had to pick up the slack from day one.

No such sophisticated safety system exists or probably can exist in sport diving, where the primary incentive for participation is recreation.

It was still puzzling, however, why so few individual components of Naval Aviation’s successful safety program had translated effectively to diving. It appeared that even the most fundamental of safety lessons learned by the Navy, such as the disciplined use of briefing checklists, had not been widely adopted outside of the military.

There’s a saying in Naval Aviation: “You need a plan to deviate from…” Without a baseline of coordinated expectations prior to a flight, a reasoned response to the inevitable surprises that crop up is impossible, especially if limited in experience.

With that in mind, I saw an obvious place to start. It seemed a no-brainer to me that a reasonably thorough briefing before a dive would be an obviously worthwhile safety enhancement for virtually every diver.

In 2004, I decided to mass produce a dive safety briefing checklist based on my experience flying A-6 Intruder carrier attack jets. The goal was to create a short, easy to use checklist that would take an experienced buddy team of sport or technical divers a nominal 30 minutes to brief the first time it was used, and then perhaps 15 minutes to review prior to subsequent dives.

The checklist was purposefully short because it was assumed that a truly comprehensive “Naval Aviation style” brief (minimum of one hour; as long as four hours for a complex strike – this does not include planning time) would meet resistance from participants in a sport motivated primarily by a desire to have fun. Whether “fun” was defined as a relaxed tropical dive on a shallow reef or a deep, highly complex wreck or cave penetration was moot. In the final analysis, sport divers share no common mission other than to have a widely varied definition of “fun.”

The checklist served as a briefing tool between dive team members as well as with surface support personnel to clearly define basic responsibilities and procedures utilized in the most common aspects of open-circuit diving. Briefing examples included such varied items as an in-depth discussion of each diver’s gear configuration and the plan for transferring an incapacitated diver from the water back into the boat.

The briefing checklist was a total failure.

Granted, it was designed for function over glitz. Printed in black and white on a hard, durable two-sided plastic card with rewritable blank spaces, it was not especially pretty. It certainly did not fit in with gear purchased by divers who cared about the color of their fins.

But I believe the failure was due to more than a lack of curb appeal. I had grossly underestimated the average diver’s willingness to slow down the “fun” long enough with what could be perceived as a 15 to 30 minute “downer” of a brief talking about all the things that could go wrong.

There was an obvious conclusion to draw: an honest understanding and desire for a culture of safety simply did not exist in diving as was enjoyed by professional aviation. Thorough briefings provide pilots with the “warm and fuzzy” of being truly prepared for any contingency. Sport divers seemed to consider a thorough briefing checklist alarmist at best and overall a nuisance of limited value.

This story serves as an illustration of the fundamental difference between diving and professional aviation that makes it exceedingly difficult, if not impossible, to incorporate the central beneficial feature of an aviation safety program into sport diving: the structural ability to develop a professional culture – or “system” – of safety.

Please do not misunderstand; there are definitely transferrable practices and procedures in professional aviation that have been or will be (and most definitely should be) adapted to diving. My point is that the limitations of utilizing an aviation safety model in total are significant and probably insurmountable.

Not recognizing this fact could conceivably lead to misplaced confidence, complacency, and potentially new, unforeseen types of mishaps to begin to develop in diving. The law of unintended consequences comes to mind.

Here’s an example.

Required aviation skills such as maintaining adequate situational awareness, or “SA,” serve as an example of a developed aptitude that might only be possible to widely implement in an organization that possesses a culture – or system – of professional safety.

SA as a practical skill can be thought of as a pilot’s mental picture of the location and attitude of his or her aircraft and all surrounding aircraft in three dimensions, the status of an aircraft’s mechanical systems, the aircraft’s progress along a navigation plan, weather considerations, communication requirements and status within the cockpit and with all outside players (for example air traffic control or other jets in a strike package), and other mission-specific considerations such as enemy threats, all updated constantly in real time.

Finally, this cumulative awareness needs to be preserved while flying an aircraft under extreme stress due to mission requirements (i.e. getting shot at) or system failure (e.g. engine fire).

When an emergency arises, none of the above listed SA components can be automatically jettisoned to accommodate a pilot’s mental capacity to handle the new situation. When a pilot is overwhelmed by new information and rapidly changing circumstances, an automatic prioritization process of identifying and disregarding the least important input at that particular point in time must occur.

“Task saturation” is the technical term for this feeling of being totally overwhelmed, of literally drowning in a sea of inputs (the sensation can initially make even breathing difficult), secure in the unsettling, deeply seated understanding that multiple complex decisions need to be made right now, and that choosing the wrong course of action will likely lead to your death or that of someone else in the flight.

There are numerous catchy phrases for task saturation, such as making room in a pilot’s “bucket” (i.e. head) for surprise decisions and tasks.

Seamless delegation and prioritization of the tasks required for mission completion, first, and survival, second, are routinely practiced by Navy pilots in extremely complex simulator sessions and during actual training flights.

A true safety system ensures that every pilot spends a significant amount of time in scheduled, recurring training with a “full bucket.”

When task saturation then occurs in the real world, as it inevitably will, the pressure of being overwhelmed is mitigated by lots of intense practice spent in this regime. Experiencing the sensation of a “full bucket” in a life and death situation is certainly still stressful, but it definitely does not come as a surprise, and it is in fact a familiar feeling.

Having the opportunity to spend time with a “full bucket” is not fun, and many pilots would probably skip the training if given the choice, that is, until they encounter a real-life situation where their “bucket over-flow-eth.” But they are not given the choice.

Many aspiring pilots wash out because they simply “can’t hack it”: they do not possess the “right stuff” to get the job done. The only way to know this for certain is through rigorous, highly complex simulations followed by closely monitored – and at times extremely dangerous – actual flights.

There’s another Naval Aviation saying, a bit hackneyed, but applicable all the same: “The more you train in peace, the less you bleed in war.”

And when all is said and done, despite hugely expensive, mandated recurring practice and testing in complex simulators, “Loss of SA” is still a frequent causal factor for many Naval Aviation mishaps.

Virtually no determined sport divers need fear being barred from diving altogether because he or she is unwilling or unable to adapt to a model approach to safety.

Operating within the unyielding confines of a true safety system offers other advantages as well. Professional aviation’s success in not making the same mistakes twice is well established. This is made possible by the requirement to document every incident and disseminate this detailed information to a centralized body for future training improvements, with the process being guaranteed by a system of strict accountability enforced by an established chain of command, either military or civilian.

DAN does a phenomenal job as a limited central clearing house for sport diving mishap summaries. Could you imagine how busy DAN would be if every sport diving incident, big and small, was required to be reported?

Now add in what if every recreational diver were required to read every single report in a timely fashion, prior to every single diver being thoroughly trained in any new procedures or policies introduced as a result of lessons learned from the mishap?

It is this type of uniformity that allows for the existence of a highly complex, but common and intuitively understood, language that reinforces a culture of safety in Naval Aviation and serves to self perpetuate these lessons as one of many intrinsic feedback loops.

A true safety system is structurally organized to constantly and automatically learn and improve.

In my opinion, the extreme demands of system standardization, training, and tested, consistent performance at the highest level, all overseen by a clearly defined and empowered chain of command with actual clout, can be described, but must be experienced to be truly appreciated.

This is in essence what produces a culture of professionalism in safety. These are the components that enable the development of a true “safety system.”

It’s my guess that the vast majority of divers do not have direct, actual experience participating in a relentlessly demanding organization such as professional aviation, and particularly military flying with its more evolved concept of allowable levels of risk.

This is the salient point: it is the entirety of many complex pieces that allow the professional aviation system to be so safe. In my opinion, a “system,” or culture of professional safety, as experienced in aviation simply does not and cannot exist in a sport conducted at the end of the day for enjoyment and lacking a chain of command, common mission or purpose, vast funding, and standards which preclude participation by a large number of aspirants.

There is much to be gained by divers in studying aviation safety practices, but as every pilot knows, complacency is the greatest danger. I would encourage sport divers to utilize the individual pieces of professional aviation practice that prove useful to safety, but also to recognize that these are but small components of the overall system and subject to significant limitations.

For diving to adopt a true safety system with the fidelity of professional aviation would require rules and resources that would defeat the purpose of the sport: to enable the average person to enjoy the underwater environment.

But that’s just my opinion; I’d love to hear yours…

The author was a Navy carrier pilot for a decade, spent another ten years flying for United Airlines, and holds a University of Washington Masters in Strategic Planning for Critical Infrastructure, a graduate program heavily reliant on systems theory and risk management.

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