
To Err Is Human: Mistakes and slips in skydiving and other disciplines - fanf2
https://blueskiesmag.com/2018/09/26/to-err-is-human/
======
kweks
I skydive and BASE; from my (limited) experience, the disciplines have a risk
of 'built in' complacency.

Take skydiving, for example. As a beginner, you're keenly aware that every
time you toss yourself out of a plane, you're committing suicide, and every
time, the parachute saves your life. Quite quickly, it can be easy to equate
"wearing a parachute" to "nothing will go wrong".

A skydive rig is an incredible feat of engineering. Each fold and stitch has a
history, a reason and a purpose. It's a thing of beauty. However, in a skydive
rig, half the system is a black box: You're not allowed to touch or handle the
reserve part. This can foster a complacency, or a shift of responsibility: It
doesn't matter if my pack was terrible, I've got my reserve..

Checklists do exist: In theory you'll check your AAD (Automatic Activation
Device - it basically fires your reserve if you haven't opened by a certain
altitude), your pins (reserve and main), your handles (pilot chute / main
handle, cut-away handle, reserve handle), straps (leg straps, chest strap),
ring system (RSL and three ring system), and then your own gear (helmet,
goggles, alti).

However, expectation of performance (IE, every time you've worn your chute
it's worked, leads to complacency), peer pressure (it's totally 'not cool' for
experienced jumpers to ask for a gear check) - rushing - and the 'laid back'
environment of dropzones erode the seriousness of the task and the importance
of stringent checking.

~~~
EliRivers
I've only ever jumped in the UK and Spain, but every dropzone I jumped at in
the UK required everyone to have a gearcheck from a suitably experienced and
qualified skydiver before boarding, and a signature against your name on the
manifest confirming it had been done.

I do know that the US had a reputation for being significantly more...
trusting of everyone to sort out their own arrangements.

I do know that in fifty-odd jumps, I checked my gear and had someone else do a
check for me once I was wearing it, every time. Good habits learned early
stick.

~~~
YeGoblynQueenne
So, it's like when you have a second pair of eyes checking your code to make
sure there's no bugs. That really helps, in software development, doesn't it?

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brownbat
With nod to Norman’s “The Design of Everyday Things,” including the chapter
“Human Error? No, Bad Design.”

For reference, an article he also wrote with that title, discussing design and
human error in major transportation accidents:

[https://www.jnd.org/dn.mss/human_error_no_bad.html](https://www.jnd.org/dn.mss/human_error_no_bad.html)

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hudibras
Having never heard of a "CYPRES fire," just spent 10 minutes googling it and
then watching terrifying skydiving videos, like this one (no injuries or
deaths, just scary):

[https://www.youtube.com/watch?v=DAZXF1UZ1Yg](https://www.youtube.com/watch?v=DAZXF1UZ1Yg)

~~~
kweks
By far the most 'well known' AAD videos. The human mind is _amazing_ in its
ability to adapt to new environments. To a non-skydiver, the most important
thing to do when you skydive is to open your parachute.

However it's stupidly easy as a jumper to forget completely about your
altitude because you're concentrating on something else. Hard to believe that
you're able to easily ignore 'certain death' after a few times - but that's
the case.

According to CYPRES documentation, they've had thousands of fires - so in
theory - saved thousands of lives - including the ones in this video. Pretty
impressive.

~~~
dotancohen
Not every CYPRES fire is another life saved:
[https://www.youtube.com/watch?v=MmOiyrsCRNA](https://www.youtube.com/watch?v=MmOiyrsCRNA)

I'm being cynical. The occasional misfire is worth every life saved. I suppose
that AAD systems are like airbags. An occasional false positive is better than
even a single false negative.

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djmips
It seems that having a checklist like in aviation (that was also applied to
surgery and other areas) could be useful to alleviate some of these slips.

[https://news.ycombinator.com/item?id=8862273](https://news.ycombinator.com/item?id=8862273)

~~~
lostconfused
Point and call

[https://www.atlasobscura.com/articles/pointing-and-
calling-j...](https://www.atlasobscura.com/articles/pointing-and-calling-
japan-trains)

Someone linked this article in a thread related to worker safety or hazards.

There always seems to be ways to improve safety or reduce failure rate. But
the problem is lack of incentive or motivation to make those improvements.

After reading the actual article. The point and call aims to eliminate the
"slip" error. By keeping the human awareness focused and engaged in the
activity.

~~~
mnw21cam
I recently went around the USS Midway museum. It struck me that the guy in
charge of the catapult would point at each person in turn waiting for an OK,
before making a very clear signal to launch. Not quite point and call, mainly
because the deck would be too noisy for the call bit, but it worked.

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clueless123
One way to mitigate slips are mnemonics.. in grain them into the students when
they are learning, and they will get stuck with them for life. I have one for
pretty much everything I do.

~~~
jobigoud
Great tip.

I wonder if exaggerated gestures and pointing with the finger, like the
Japanese railway operators do would help. I'm going to start doing this myself
during my checks (beginner paraglider).

~~~
clueless123
That is exactly how we do them.. you say the word and point to the item with
the hand you will be using.

Ex: When landing the plane: GUMPS (gas, undercarriage, mixture,prop,seatbelts
) say them all while pointing to each item.

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blablablerg
The theory in this article is based on "Human Error" by James Reason.

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imatworkhandle
I get this mag. Never would I think Id see a link to it here.

