This presentation was given at the Eurotek 2012 technical diving conference and tries to highlight the challenges in changing and developing a safety culture within the sport of recreational and technical diving.
A panel of top industry professionals provide their expert opinions on current hot-button legal topics and their impact on your operations. Topics include:
• OSHA investigations
• The borrowed servant doctrine and its impact on the relationship between crane companies and their customers
• How you should respond to accidents
• Recovering from at-fault parties and employees for damage to your crane and other property
Moderator: Fred Marcinak, Attorney-At-Law, Smith Moore Leatherwood LLP
Panelists:
Bill Smith, Executive Vice President, Nations Builders Insurance Services, Inc. (NBIS)
Matt Stone, Attorney-at-Law, Smith Moore Leatherwood LLP
Jim Wiethorn, Principal Engineer/Chairman, Haag Engineering
A panel of top industry professionals provide their expert opinions on current hot-button legal topics and their impact on your operations. Topics include:
• OSHA investigations
• The borrowed servant doctrine and its impact on the relationship between crane companies and their customers
• How you should respond to accidents
• Recovering from at-fault parties and employees for damage to your crane and other property
Moderator: Fred Marcinak, Attorney-At-Law, Smith Moore Leatherwood LLP
Panelists:
Bill Smith, Executive Vice President, Nations Builders Insurance Services, Inc. (NBIS)
Matt Stone, Attorney-at-Law, Smith Moore Leatherwood LLP
Jim Wiethorn, Principal Engineer/Chairman, Haag Engineering
You are mistaken if you think that asbestos is the problem in the past. This toxic material, which can cause lung cancers and mesothelioma, is still present in two-thirds of Australian houses
Jacob Newberger has functioned as an automation validation engineer with Panacea Technologies, Inc., in Montgomeryville, Pennsylvania, since 2011. Beyond his professional responsibilities Jacob Newberger enjoys staying physically active through skiing and scuba diving.
Accident Investigations - Blame and Shame or Listen and Learn? SAMTRAC International
Are all accidents preventable? Steve Woodward walks NOSHCON 2015 attendees through the seven delusions under which safety officials function, and challenges outdated, unsafe habits.
"Obvious Errors: Anything but simple" - Don't Judge when you don't know the w...Gareth Lock
A presentation given at the 2013 Global Diving Conference (https://www.facebook.com/globaldiving) in Portugal. The presentation focusses on the fact that it is very easy to judge after an incident has happened but there are many inter-dependent factors at play when an incident occurs.
Highlights from the Risk Management Perspectives Conference organised by the Society of Actuaries in Ireland (SAI) in November 2014.
For more information on the SAI, go to: www.actuaries.ie
Please feel free to share this presentation and connect with me in LinkedIn.
The Base Rate Fallacy - Source Boston 2013Patrick Florer
A base rate is the prevalence of an item of interest in a population. In medicine, it would be the prevalence of a disease in a group of people. In information security, it might be the prevalence of sql injection flaws in web applications or the prevalence of malware in the population of downloaded *.exe files. Without an estimate of the base rate, it isn’t possible to talk meaningfully about detection rates (true positives) or false positives. Those who do so commit the “base rate fallacy. If the base rate is known, then a Fourfold table, also called a 2 x 2 table or matrix, is a mechanism that helps us understand the correct probabilities of True Positive, False Positive, True Negative, and False Negative events and avoid the base rate fallacy. Understanding these probabilities enables us to evaluate the claims of many types of security technologies, including the effectiveness of antivirus software, web application scanners, and IDS/IPS systems.
• The base rate fallacy will be explained and demonstrated.
• Gigerenzer’s Natural Frequencies Technique for Avoiding the Base Rate Fallacy
• Examples of why base rates apply to information risk management:
Common Vulnerability Scoring System (CVSS)
The Distinction between Inherent Risk vs. Residual Risk
Intrusion Detection Systems
Vendor Management, Hosting Providers, and SOC 2 (formerly SAS70) Audit Reports
You are mistaken if you think that asbestos is the problem in the past. This toxic material, which can cause lung cancers and mesothelioma, is still present in two-thirds of Australian houses
Jacob Newberger has functioned as an automation validation engineer with Panacea Technologies, Inc., in Montgomeryville, Pennsylvania, since 2011. Beyond his professional responsibilities Jacob Newberger enjoys staying physically active through skiing and scuba diving.
Accident Investigations - Blame and Shame or Listen and Learn? SAMTRAC International
Are all accidents preventable? Steve Woodward walks NOSHCON 2015 attendees through the seven delusions under which safety officials function, and challenges outdated, unsafe habits.
"Obvious Errors: Anything but simple" - Don't Judge when you don't know the w...Gareth Lock
A presentation given at the 2013 Global Diving Conference (https://www.facebook.com/globaldiving) in Portugal. The presentation focusses on the fact that it is very easy to judge after an incident has happened but there are many inter-dependent factors at play when an incident occurs.
Highlights from the Risk Management Perspectives Conference organised by the Society of Actuaries in Ireland (SAI) in November 2014.
For more information on the SAI, go to: www.actuaries.ie
Please feel free to share this presentation and connect with me in LinkedIn.
The Base Rate Fallacy - Source Boston 2013Patrick Florer
A base rate is the prevalence of an item of interest in a population. In medicine, it would be the prevalence of a disease in a group of people. In information security, it might be the prevalence of sql injection flaws in web applications or the prevalence of malware in the population of downloaded *.exe files. Without an estimate of the base rate, it isn’t possible to talk meaningfully about detection rates (true positives) or false positives. Those who do so commit the “base rate fallacy. If the base rate is known, then a Fourfold table, also called a 2 x 2 table or matrix, is a mechanism that helps us understand the correct probabilities of True Positive, False Positive, True Negative, and False Negative events and avoid the base rate fallacy. Understanding these probabilities enables us to evaluate the claims of many types of security technologies, including the effectiveness of antivirus software, web application scanners, and IDS/IPS systems.
• The base rate fallacy will be explained and demonstrated.
• Gigerenzer’s Natural Frequencies Technique for Avoiding the Base Rate Fallacy
• Examples of why base rates apply to information risk management:
Common Vulnerability Scoring System (CVSS)
The Distinction between Inherent Risk vs. Residual Risk
Intrusion Detection Systems
Vendor Management, Hosting Providers, and SOC 2 (formerly SAS70) Audit Reports
2008 Personal Watercraft Safety Review for Big Wave Surfing and Tow SurfingK 38
2008 Review of the year regarding big wave surfing safety and personal watercraft use for tow surfing and or rescue applications by K38's founder, Shawn Alladio a world authority subject matter expert regarding RWC usage
Overview of the JARUS Specific Operations Risk Assessment ProcessTerrence Martin (PhD)
This set of slides covers off on the JARUS SORA Process, and corrects some of the interpretation errors I made in other presentations.
Whilst this has not yet been adopted in Australia, the CASA UASSC is currently examining its merits.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
TESDA TM1 REVIEWER FOR NATIONAL ASSESSMENT WRITTEN AND ORAL QUESTIONS WITH A...
Culture. Isn’t just something that grows in the lab (or kitchen)...
1. Culture. Isn’t just something
that grows in the lab (or kitchen)...
Improving Diving Safety Through Improved
Reporting and a Just Culture
Gareth Lock
E: gareth.lock@cognitas.org.uk M: 07966 483832
2. Scope
• Risk
• Cultures
• What is an Incident?
• Reporting, why should I?
• Case Studies
• Reporting Opportunities
• DISMS
• Conclusions
3. Introduction
• Full time RAF Officer
(ex C-130 aircrew)
• Adv Trimix Diver
• Studying for PhD
Cranfield
• Cognitas in 2010
• DISMS launched Apr 2012
13. Risk, What is It?
• Diving is risky
• Baselines are required
• What is risk?
14. Risk, What is It?
• Diving is risky
• Baselines are required
• Understand the risks
• What is risk?
15. Risk, What is It?
• Diving is risky
• Baselines are required
• Understand the risks
• Educate but don’t scare
• What is risk?
16. Risk, What is It?
• Diving is risky
• Baselines are required
• Understand the risks
• Educate but don’t scare
• Mitigate and reduce them
• What is risk?
17. Risk, What is It?
• Diving is risky
• Baselines are required
• Understand the risks
• Educate but don’t scare
• Mitigate and reduce them
• To improve safety, not primarily
reduce litigation
• What is risk?
19. Risk, What is It?
zIncident
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Safety Margin
20. Risk, What is It?
zIncident
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Human Error!
(Active/Latent)
21. Risk, What is It?
z
Resources
Incident
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Human Error!
(Active/Latent)
22. Risk, What is It?
z
Resources
Incident
Bad Luck!
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Human Error!
(Active/Latent)
23. Risk, What is It?
z
Resources
Incident
Bad Luck!
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Human Error!
(Active/Latent)
Training
24. Risk, What is It?
z
Resources
Incident
Bad Luck!
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Human Error!
(Active/Latent)
Training
Feedback
25. Risk, What is It?
z
Resources
Incident
Bad Luck!
Safe Limit for
Recreational
Diving
Safe Limit for
Technical!
Diving
Human Error!
(Active/Latent)
Training
Reporting
Feedback
28. 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)
38. Reporting Culture Survey
• Percentage of Divers Had
Incidents?
• Types of Incidents
• Knowledge of the BSAC
system
• Reasons for not reporting
• DCI Occur vs Report
48. Reporting Culture
• Improvements are
needed
• Guidelines on what is an
Incident
• Independence may
improve uptake
• Easy to submit report
• Useful outputs
• Promotion of Reporting
49. 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
53. 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’
54. 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’
56. 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.
57. 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.
59. What is an Incident?
• Unplanned separation at depth, solo ascent
60. What is an Incident?
• Unplanned separation at depth, solo ascent
• OOG back gas just before end of BT
61. What is an Incident?
• Unplanned separation at depth, solo ascent
• OOG back gas just before end of BT
• Twin indies, end dive 20bar/210bar
62. 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
63. 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
64. 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
65. 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
66. 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
67. 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
68. 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
70. What is an Incident?
• 10% Lack of Clarity
• More guidance required
71. 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
73. Case Study One
MCCR Shutdown
• Experienced Trimix
Instructor, Relatively New
CCR Diver
Image from www.kissrebreathers.com
74. Case Study One
MCCR Shutdown
• Experienced Trimix
Instructor, Relatively New
CCR Diver
• Forgetting O2 shutdown post
dive
Image from www.kissrebreathers.com
75. 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
76. 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
77. 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
79. Case Study One
MCCR Shutdown
• Reported: Diver
shutdown O2 in water.
Broke ‘rules’.
Image from www.kissrebreathers.com
80. 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
83. Case Study Two
CCR Narcosis
• Experienced MOD 3 level
CCR Diver
• Stressful previous days
84. Case Study Two
CCR Narcosis
• Experienced MOD 3 level
CCR Diver
• Stressful previous days
• Issues on descent, carried
on despite ascending to clear
85. 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!
86. 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
88. Case Study Two
CCR Narcosis
• Likely Reported:
Potential narcosis
leading to bailout
89. 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
93. Reporting, Why Should I?
• What is the Risk?
• How Big Is the Problem?
• Where is the Problem?
94. Reporting, Why Should I?
• What is the Risk?
• How Big Is the Problem?
• Where is the Problem?
• Reason’s Swiss Cheese Model
• Organisational Influence
• Unsafe Supervision
• Pre-Condition for Unsafe Acts
• Unsafe Acts
95. Reporting, Why Should I?
• What is the Risk?
• How Big Is the Problem?
• Where is the Problem?
• Reason’s Swiss Cheese Model
• Organisational Influence
• Unsafe Supervision
• Pre-Condition for Unsafe Acts
• Unsafe Acts
•How To Stop It Happening Again?
104. Reporting, Why Should I?
• Data Provision
• Safety conferences, lack of data
• Insurance and financial implication
105. Reporting, Why Should I?
• Data Provision
• Safety conferences, lack of data
• Insurance and financial implication
• Lessons Learned
106. 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
107. 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
128. Areas for Improvement
• More Analysis Needed in Reports
• Increase number of filter options
• Improve drop down options esp CCR
129. 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
132. Summary
• More opportunity for ‘Lessons Learned’
• Easier to address than total stats
capture, probably greater impact too
133. Summary
• More opportunity for ‘Lessons Learned’
• Easier to address than total stats
capture, probably greater impact too
• Needs stronger Reporting Culture
134. 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
135. 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
136. Questions?
“From a safety perspective, it is not
criminal to make an error, but it is
inexcusable if you don’t learn from it” -
Wiegmann/Shappell 2003
www.cognitas.org.uk http://www.divingincidents.org