Julian Barthel identifies seven layers that protect us from having an incident in skydiving
Once you have spent a little time on dropzones, unfortunately, you will eventually witness an incident, a close call or an accident.
When we dissect how any given incident unfolds, the grand majority of cases turn out to be a chain of events that did not get interrupted in time.
How the cause of the incident gets interpreted and corrective measures are taken to prevent similar future incidents can vary greatly in approach and efficiency and has potential to fundamentally shape the culture of how people deal with mistakes and resulting learning opportunities.
People or Systems?
There are two fundamentally different approaches to incidents:
Person approach
The traditional Person Approach blames the individual for weaknesses like forgetfulness, negligence, inattention, fatigue and other possible human causes of incidents. Preventative measures range from blame, naming and shaming and disciplinary measures to campaigns aimed at people’s sense of fear and other techniques based on fear and guilt.
System approach
The System Approach on the contrary views the human factor as a risk to be aware of and tries to optimize the conditions for people, educate and learn from past mistakes and create safety margins to prevent future incidents from happening. Mistakes are seen as vital learning opportunities to make the system more robust so they don’t happen again in the future. This fosters a reporting culture free of blame and allows the individual to admit mistakes and as a result. It also grants the community the chance to analyze, learn and grow from them.
The Swiss Cheese Model
When talking about the system approach to accidents, the most cited theory and relevant model because of its systemic foundations is “The Swiss Cheese Model of System Accidents”1. Originally developed by James Reason in the late 1980s it is still used today in risk analysis and risk management, including aviation safety, engineering and healthcare Among many more. The Swiss Cheese Model specifically looks at a system’s different safety layers that are in place to protect it from incidents. Each intervention (layer) has imperfections (holes). Multiple layers improve protection.
Infograph by FlyinMynd
Reason’s model looks at the system as a whole where ideally each protective layer is solid and intact. In reality these layers have holes in them which can be either active failures – unsafe acts committed by people, or latent conditions – flaws in system design which create favorable conditions for incidents.
The holes in each layer are not always present however. They are constantly appearing, disappearing or moving. If a threat moves through a hole in a layer, most of the time it gets stopped by the next layer. An incident happens when holes in all layers momentarily line up and allow the trajectory of a threat to pass and bring the individual in contact with potentially harmful circumstances.
7 Layers
In Skydiving I have identified seven protective layers that shield us from harmful incidents. As described by James Reason, there are safety layers which protect us from threats that range from completely individual, such as mindset and attitude of each person, to organisational layers like rules and regulations, as well as external factors like the environment. These layers build a complex and ever moving system. What is important is that the last layer, the safety net, is our community . How we show up and watch out for each other.
The 7 Protective Layers in Skydiving:
- Mindset/Attitude
- Education
- Regulation
- Equipment
- Environment
- Human Factor
- Community
All of the layers and factors are intricately interlaced and build a complex and ever-evolving system.
Image: Harry and Alabama Shanker by FSU
Layer 1: Mindset/Attitude
At the base of it all lays the one fundamental variable that determines all risk:
YOU
• Your Mindset of how you approach the sport
• Your sense of responsibility towards other jumpers and the community
• How you evaluate risk
• How you make choices
• How you look at your own ability and room to grow
As we all know, our mindset is constantly evolving. We form new perspectives, gain experience and confidence. As our confidence grows it is important to have a sober look at our self from time to time and be able to realistically self-assess where we stand in our abilities and how they currently measure up with the challenges we set for ourselves. Equally important is the ability to ask for and receive constructive criticism from peers and friends. Doing this well can keep our ego in check and avoids falling into the complacency trap, which in turn can avoid unsafe choices.
Initially it is counterintuitive to search for dialogue about our mistakes and use them as a learning opportunity for ourselves and our peers, especially if nobody witnessed them. We need to overcome our ego, lead by example and openly admit mistakes to prevent a culture of shame and blame. When an individual admits a mistake and grants the community the chance to analyze, learn and grow from it, we must honor the effort and engage in dialogue to foster a reporting culture free of blame.
At the same time, it is vital to maintain a growth mindset. We need to do our best to put ourselves in the student position:
Stay hungry to learn, question everything we know, explore, re-imagine and change perspective. We can learn something from every person and interaction. Like this we maintain respect for what we do and stay open to evolve with the times. If our Ego takes over, if we believe we know everything, if we stop listening and feel like nothing can hurt us, or simply get cocky or complacent, we’re setting the stage for a very painful awakening.
Our Attitude is at the center of how we perceive everything. It is the filter through which we see the world and interpret and act on what we experience. Because of that, I have identified Mindset and Attitude as the first and most basic safety layer in our sport.
Image supplied by Skydive Cross Keys
Layer 2: Education
The dropzone where we receive our training. Our skydiving peers and what is accepted as safe in our home dropzone form the safety culture that is instilled in us and greatly affects how we interpret potentially dangerous situations and make safety decisions.
• Are regulations and recommendations taken seriously at your DZ?
• Are uncomfortable or difficult problems talked about, even if they can’t have clear-cut answers?
• Are people held accountable for unsafe actions?
• Are further educational opportunities put in place to give people a chance to learn from mistakes?
• Is a normalization of deviance tolerated?
Our education doesn’t stop at what we can learn from our dropzone and peers, but knowledge has to be pursued. We are responsible for educating ourselves, traveling to different places and searching for knowledge. We need to go and see other dropzones, experience how things are done differently and see for ourselves what is out there. Exchanging information, being exposed to different sources and opinions, different situations and varying ways of dealing with them, are massive learning opportunities that form an irreplaceable part of our education as skydivers.
We are responsible for educating ourselves and searching for knowledge
As a novice we are like a blank slate, so the first contact we have with the sport will make a big impact on how we perceive situations and risk. The education we receive from our mentors and community should lay a solid foundation of understanding of good practices and expose us to the tools we need to properly evaluate risk. Our attitude helps us absorb and expand our knowledge. It is our own responsibility to explore what is out there and keep building on this foundation to build experience.
Image: Kris Cavill and Milko teaching AFF at Skydive Hibaldstow, by Martin Skrbel
Layer 3: Regulations
Rules and Regulations are the guidelines and rules of engagement that are designed to keep us safe. Initially it is easy to feel that authorities like ground controllers, chief instructors or load masters are the fun police and are out to get us. We need to remember that in order to discover the rules that exist in our sport, often one or more people paid with their life. Honoring them is in the interest of our safety, to protect the dropzone and the ability to continue practicing our sport in a self-regulated fashion. These rules can range from jump limits to minimum safety standards for equipment or minimum experience and training to jump a certain canopy.
Remember that in order to discover the rules that exist in our sport, often one or more people paid with their life
In the same train of thought it is important to respect and honor minimum license requirements, as they are proof of minimum experience and often allow us to participate in instructional rating courses. If we get the experience that is required for a license signed off without actually having done what is necessary and then become instructional rating holders ourselves, what chance of an education does the next generation of skydivers really have?
Proper guidance can make all the difference. The goal is to seek out mentors that are not afraid to go the extra mile and support us in our journey to become knowledgeable skydivers. If we are lucky enough to surround ourselves with great mentors and friends who help us grow, it becomes the logical next step to give back to the community and mentor the next generation, regardless of whether we choose to get a rating or not. Some of the best mentors I know in our sport do not hold an official Instructional rating, and some of the worst do.
Image: Pete Allum by Vit Kaven
Part Two
Part 2 covers the other four protective layers:- Equipment, Environment, Human Factor and the Community – and draws conclusions about how understanding the Swiss Cheese Model can help keep all of the skydiving community safer.
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