Advanced Engineering Informatics 51 (2022) 101520

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Advanced Engineering Informatics

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Full length article

Development and validation of a confined space rescue training prototype

based on an immersive virtual reality serious game
Song Lu a, b, Fei Wang a, b, *, Xin Li c, Qichuan Shen b
a
Department of Engineering Physics, Tsinghua University, Beijing, China
b
Shenzhen International Graduate School, Tsinghua University, Shenzhen, China
c
Foshan Urban Safety Research Center Co., Ltd, China

A R T I C L E I N F O A B S T R A C T

Keywords: Due to the inherently hazardous nature of the confined space environment and a lack of effective rescue training
Confined space rescue on on-site personnel attempting the rescue of fellow workers in a confined space, accidents or even multiple
Safety training fatalities may happen. For this reason, improving the skill set of rescuers is of vital importance. Immersive virtual
IVR SG
reality serious games (IVR SG) have been shown to be effective and are now widely used in safety training.
E-lecture
However, there is little research on its application in confined space rescue training. To bridge this gap, we have
developed a confined space rescue training system (called Rescue Success) based on IVR SG, and then tested its
effectiveness in a real environment. We carried out a single-blind, randomized comparative experiment to study
and compare the learning effectiveness of using IVR SG compared to an E-lecture in terms of behavioral skills,
knowledge acquisition, self-efficacy, and simulation-induced sickness. Our results show that both training
methods significantly improve the participant’s rescue behavioral skills, knowledge, and self-efficacy. Overall,
IVR SG performed better than an E-lecture in all aspects except simulation-induced sickness, where there is no
difference between the two methods.

1. Introduction
Confined space accidents are the source of many casualties world­
wide [1]. However, the fatality rate of confined space rescuers recently
in China has been much higher than what is typically found in some
developed countries. For example, the Safety Office of the State Council
of China recorded 21 confined space incidents between 2017 and 2018,
resulting in 75 fatalities where 71% of them were rescuers [2]. By
comparison, in the United States, the U.S. Bureau of Labor recorded 458
confined space accidents from 1997 to 2001, where the fatality rate of
rescuers accounted for only 5.5% of the total death toll [3]. Moreover,
an investigation of 59 confined space accidents in Australia from 2000 to
2012 showed that the fatality rate of rescuers accounted for only 3.4% of
the death toll. According to the Ministry of Emergency Management of
China, the main reason for the high mortality of rescuers is a phenom­
enon known as “blind rescue,” which refers to a situation where rescuers
attempt to save fellow workers while lacking sufficient knowledge of
standard rescue procedures [4].
Effective training methods based on standard rescue procedures
regulated by the government can be used to solve this problem [5,6].
Many studies have indicated that IVR SG with advantages such as high-
immersive, low-cost can significantly improve the safety training
effectiveness [7–9]. Considering the effectiveness of IVR SG and its po­
tential to solve “blind rescue”, it is necessary to explore the confined
space rescue training based on IVR SG.
To design and apply a confined space rescue training prototype, we
need to face the following three challenges: (1) The environment and
interactions of the IVR SG system need to be realistic so as to help
personnel transform knowledge and skills into rescue behaviors in real
scenarios. (2) Due to the dangerous nature of the confined space during
rescue training, the system should emphasize avoiding wrong behaviors
that may cause deadly secondary accidents. (3) A well-designed verifi­
cation experiment is needed to prove that the training system is more
effective than the traditional training method.
To address the above three challenges. This paper firstly developed
an IVR SG training system to transfer the rescue procedural knowledge
and behavior skills to the rescuer. A confined space operation scenario
and the models of the required rescue equipment were built to create an

* Corresponding author at: Department of Engineering Physics, Tsinghua University, Beijing, China. Shenzhen International Graduate School, Tsinghua University,
Shenzhen, China.
E-mail address: wang.fei@sz.tsinghua.edu.cn (F. Wang).

https://doi.org/10.1016/j.aei.2021.101520
Received 7 August 2021; Received in revised form 30 November 2021; Accepted 30 December 2021
Available online 13 January 2022
1474-0346/© 2022 Elsevier Ltd. All rights reserved.
S. Lu et al.
immersive virtual environment. According to the rescue procedures
specified in relevant policies and regulations, we developed the proper
training storyline. In particular, we simulated the rescue behavior of the
personnel to make it similar to the real one. Secondly, a dynamic error-
consequence mechanic based on fault tree analysis is proposed to meet
the second challenge. Experiencing severe consequences caused by
wrong behaviors in advance can enhance the safety awareness of res­
cuers and help them avoid blind rescue. Thirdly, we set up a random
comparative test to verify Rescue Success’s effectiveness compared to
the E-lecture training method.
We first introduce related work on using VR as a training tool to
enhance the performance of rescuers, fault tree analysis, as well as
studies comparing VR training with alternative training methods (Sec­
tion 2). We next illustrate the development of Rescue Success in detail
(Section 3). The study of the effectiveness of IVR SG training and E-
lecture training, as well as the results and discussion, are presented in
Sections 4 and 5, respectively, while Section 6 provides conclusions and
suggestions for future work.
2. Related work
2.1. Rescue training using IVR SG
Virtual reality (VR) is a simulated experience that can be very similar
to the real world [10], which is usually applied in fields such as edu­
cation, games et al. [11,12]. IVR SG is a method of using virtual reality
integrated with games for non-entertainment purposes [13]. Previous
study suggested that VR training may cause simulator sickness [14]. But
experts found that the discomfort could be reduced through or elimi­
nated with the improvement of hardware and interaction design [15].
Currently, this method is widely used in safety training such as earth­
quake evacuation [16], aviation emergency response [9], and building
fire wayfinding [17].
Few studies on emergency rescue training using IVR SG have been
carried out. Sun et al. established a helicopter rescue training system
that transforms the complex rescue procedure into a set of virtual sce­
narios (from equipment inspection, fly to the accident site, to return) to
train the team members using head-mounted VR [18]. Xu et al. estab­
lished a rescue training system for railway accidents to train the oper­
ator to operate a rescue crane in a VR environment [19]. These studies
indicated that personnel can become familiar with practical knowledge
before rescue using VR. In this case, rescuers can better prepare them­
selves for emergency rescue when facing huge risks. However, nearly no
studies have focused on confined space rescue and little is known about
the applicability and effectiveness of IVR SG to improve the rescue skills
and knowledge of participants in confined space sites. To bridge these
gaps, we have established a full-process rescue training system.
2.2. Fault tree analysis
The essence of Fault tree analysis (FTA) is a kind of logic tree dia­
gram that uses Boolean logic symbols to represent the sources of specific
fault events and their logical relations, which can find out all kinds of
inherent potential risk factors systems in detail [20]. Previous studies
show that a fault tree can be used as a qualitative tool to ascertain likely
causes and how accidents occur [21–23]. However, no research has yet
used FTA to build an accident logic system in a 3D virtual environment
to respond to personnel errors and reduce the gap between the virtual
world and the real world.
2.3. Validation of VR training
A VR training environment is judged on its ability to elicit positive
transfer to the real world [24]. The VR environment needs to be just real
enough to develop new skills that can be applied to real tasks to achieve
this goal. Since learning real behaviors requires people to feel presence
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Advanced Engineering Informatics 51 (2022) 101520
and immersion in a virtual environment, it is essential to evaluate the
realism of the virtual training environment based on quantitative or
qualitative methods [25,26]. Another critical aspect of evaluation is the
effectiveness of virtual exercises to transfer knowledge or skills. Previous
studies mainly used self-reporting methods to test the knowledge
learning effects of virtual exercises and used virtual environments or
field tests to test skills learning effects [27–30]. In addition, many
studies have also used physiological and psychological indicators such
as self-efficacy, simulated motion sickness, heart rate, pulse, and skin
electroporation to evaluate the effectiveness of VR training [31–35].
Feng et al. built an earthquake evacuation drill system and verified
personnel knowledge acquisition, self-efficacy, and proved that the
personnel’s knowledge and skills in handling earthquake evacuation had
been significantly improved through the training [13]. It is believed that
virtual practice methods should be compared with traditional training
methods, such as videos, lectures, PPT, and so on, to enhance virtual
reality education’s compelling persuasiveness [36]. Lovreglio et al.
compared fire extinguisher training using a VR simulation with a
noninteractive training video and evaluated the trainee’s learning of a
fire extinguisher’s essential operation in terms of knowledge acquisition,
retention of information, and change of self-efficacy. The results showed
that the VR trainees outperformed the other group in all outcome pa­
rameters [7].
However, there are no current comprehensive evaluation indicators
for a virtual reality rescue training system. Moreover, in emergency
rescue training, no field experiments have been conducted to test the
learning of skills or behaviors, which makes it difficult for rescuers
receiving emergency rescue training to agree with the effectiveness of
this training method. In order to solve the above problems, we propose a
random comparative test to determine a complete evaluation system and
test the effectiveness of rescue behavior learning through field studies.
3. Development of rescue success
Rescue Success is based on our earlier conference version [2]. The
development of the system is divided into the following five parts:
design purpose, virtual environment design, storyline and interaction,
disaster simulation based on accident tree analysis, and instructional
methods.
3.1. Design purpose
This system is built to transfer procedural knowledge and behavioral
skills of confined space rescue to on-site rescuers. There are two main
reasons for choosing on-site rescuers as training targets: (1) Among
rescuers, most fatalities are among those present on-site at the time of
the incident, who often lack adequate safety training to execute a suc­
cessful rescue [1]. (2) In a time-sensitive situation like a confined space
rescue, the arrival of professional emergency services may be too late
[3].
To improve the training effectiveness of the system, we propose two
crucial design points: (1) Inspired by experiential learning theory [37],
the system provides the trained personnel with an opportunity to
practice the operations thoroughly, and therefore master the rescue
procedure in a high-fidelity virtual environment. (2) Inspired by the
learning by mistake theory [38], the system emphasizes rescue prepa­
ration by allowing personnel to make mistakes at this stage and shows
the consequences (e.g., explosion, poisoning, drowning) of errors based
on our errors-consequences mechanism.
Moreover, to increase the survival rate of rescuers before the arrival
of professional emergency medical services, a simplified Basic Life
Support (BLS) protocol of CPR & ECC guideline 2020 [39], an advanced
CPR & AED method, is also transferred in IVR SG.
S. Lu et al.
3.2. Virtual environment design
A typical sewer hole in City H was selected as the simulated rescue
scene to test our Rescue Success software. There are two primary reasons
for choosing a sewer hole as the rescue scene: (1) March to September is
the annual rainy season in City H, and there are typically a large number
of underground sewage dredging operations taking place, which, ac­
cording to the statistics of the municipal emergency management
department, are the source about half of the total number of confined
space accidents. (2) The sewer hole is a very typical confined space that
includes nearly all common hazards of confined space such as oxygen
deficiency, toxic airborne contaminants, flammable atmospheres, the
risk of engulfment in free-flowing solids and liquids, and a range of
physical hazards [40]. Therefore, a utility hole will be an ideal training
place to help rescuers identify and control hazards.
We reconstructed a real confined space operation scene. Construc­
tion of the virtual model of the utility hole and the available equipment
was completed using 3Dmax. Models of personal protective equipment
used by the rescuer are shown in Fig. 1, including a safety helmet,
positive pressure respirator, safety belt, protective clothing, and
disposable respirator. Standard emergency rescue equipment includes
medical boxes, ventilators, gas detectors, automatic external de­
fibrillators (AED), communications equipment, tripods, ladders, and
other vital tools. The building information modelling (BIM) represen­
tation of a street view in City H was introduced as the surroundings.
To construct our Non-Player Character (NPC), we used the low-cost
and high-quality human body model generation algorithm [2]. The
above models are sophisticated enough to ensure that the nuances of a
lifelike rescue scene are accurately reproduced. Finally, we imported the
above model into Unity to build the virtual environment (see Fig. 2), an
integrated platform used as a gaming engine and framework, and used
C# for interaction design [41].
3.3. Storyline and interaction
The confined space rescue procedure recommended by the Ministry
of Emergency Management of China is shown in Fig. 3 [5]. The rescue
procedure is divided into three stages: rescue preparation, rescue action,
and lifesaving first aid. When a confined space accident occurs, rescuers
should choose the rescue methods according to the scene’s character­
istics under the premise of ensuring their safety. In our system, since the
risk of non-entry rescue is significantly less than that of an entry rescue,
the system uses animation to display non-entry rescue (including self-
rescue) methods if the non-entry rescue mode is choosen. By contrast,
entry-rescue training, which is the most hazardous method, is the pri­
mary goal of the training system. Confined space rescue experts and
Fig. 1. Equipment model used in Rescue Success.
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Advanced Engineering Informatics 51 (2022) 101520
lifesaving first aid experts were invited to give the recommended be­
haviors and skills descriptions of entry rescue in all three rescue stages;
A total of 10 recommended behaviors for rescuers in the three stages are
listed, as shown in Table 1.
IVR SG has been designed to teach how to rescue the trapped person
in a confined space. At first, to ensure that the user is acquainted with
the emergency rescue equipment, a simple explanation of the name and
purpose of each item is given by an NPC before the drill. When a
confined space accident is initiated, the training session begins.
In the rescue preparation stage, we adopted the learning by mistakes
theory, so the three recommended behaviors shown in Table 1 will be
given only at the beginning of the stage using text and voice, as shown in
Fig. 4. The system will not give any more prompts while a user tries to
apply the recommended behavioral skills in this stage. After the user
decides they finished rescue preparation, they can directly click the “Go
down the manhole” box in the virtual drill to switch to the next stage. If
incorrect operations that lead to accidents (explosion, poisoning) have
been completed in the first stage, the severe consequences will be dis­
played (see Section 3.2). After that, the feedback of performance in the
first stage will be provided using the summary chart, and the user is
supposed to restart rescue preparation until they perform right.
In the rescue action stage, the system will navigate the user to
complete each behavior of the rescue action stage using the action-
driven method [42]. Guidance will be given to ensure participants
perform each behavior correctly. Moreover, to remind trainees that the
rescue process is time-sensitive, we stipulate that if the user stays in the
confined space for more than two minutes, it will be flooded with
sewage leading to drowning and failure of the rescue.
In the life-saving first aid stage, we transfer the procedure of
simplified BLS, as shown in Table 1. The guidance that ensures correct
behavior is also given in this stage. Moreover, to improve the CPR and
AED performance of users, we first try to improve the quality of CPR
(hand position, frequency, and depth) through interactive training.
Chest compression is simulated by shaking a handle to create a collision
between the hand and human body model. Motion capture algorithms
are used to calculate the frequency of the handle shaking and give
feedback to the user. If the pressing frequency is between 100 and 120
repetitions/min, the feedback will be green (satisfactory; see Fig. 5(i));
otherwise, it is red (unsatisfactory). In addition, the positioning module
is used to detect whether the trainee’s hand position is correct. Another
indicator that affects chest compression is the depth of compression. We
used three human deformation models (1 cm, 5 cm, and 10 cm), and the
system fed back the corresponding model according to the shaking
amplitude of the person’s handle.
Second, we simulated AED feedback and voice guidance, including
instructions such as turning on the switch, attaching electrodes,
S. Lu et al.
Fig. 2. Confined space work scenario in Unity (a. Overall scene; b. Internal structure of sewer hole).
Fig. 3. Basic procedures for safe rescue in work accidents in confined space (for
rescuer only).
Table 1
Recommended behavior in sewer hole rescue (entry-rescue).
Stages Recommended behaviors
Rescue 1. Detect hazards
preparation
2. Eliminate the hazards
3. Wear Personal protective
equipment (PPE)
Rescue action 4. Use the rescue system
5. Wear disposable
respirators for personnel
6. Bind personnel to the
rescue system
7. Evacuate quickly
Life-saving 8. Determine if the person
first-aid has had a cardiac arrest
9. Perform
cardiopulmonary
resuscitation (CPR)
10. Use automatic external
defibrillator (AED)
Skills Description
Use a gas detector to detect the
manhole hazards and maintain
detection.
Use a ventilator for ventilation and
maintain ventilation.
Choose proper equipment
according to the hazards detected.
Use the tripod.
Wear respirators for personnel.
Bind personnel to the rescue
system.
If the environment is dangerous,
evacuate immediately.
Check the person’s breathing and
pulse.
Perform chest compression and
artificial respiration. (If the trapped
person has been exposed to a toxic
environment, artificial respiration
should not be performed).
Use AED after performing CPR.
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Advanced Engineering Informatics 51 (2022) 101520
Fig. 4. Prompt for overall instruction of rescue preparation.
automatic detection, charging, and defibrillation, to replicate actual
AED to assist the rescuers. Each step of operating AED in the virtual
world is implemented using C#.
3.4. Error-consequence mechanism based on fault tree analysis
In a confined space rescue, people often rescue blindly because they
do not appreciate the severe consequences of an error [43]. Therefore, to
fully demonstrate the risks inherent in a blind rescue, we simulated
common confined space hazards (explosion, poisoning, drowning; as
shown in Fig. 5) using the particle system of the Unity3D engine. For the
simulation of explosion and poisoning hazards, we used the fault tree
analysis method to establish the accident causation logic [44,45]. For
drowning, we assume there is rising sewage in the well, and people will
be submerged if they do not evacuate quickly. We also simulated the
explosion mechanism based on the analysis of 10 explosion accidents
during confined space rescues, as shown in Fig. 6.
According to Fig. 6, the minimum path set for an explosion can be
obtained in the cases of: X1, X3, X4; X2, X3, and X4. The system assumes
that hydrogen sulfide is present as a hazard, and the conditions for
reaching the explosive limit are preset to be met. Therefore, if the person
fails to take corrective actions in the rescue preparation stage, such as by
carrying a mobile phone or using non-explosion-proof lights, and there is
no ventilation, an explosion will occur. If mistakes in the first rescue
stage have the potential to cause both explosion and poisoning, the
priority is explosion before the poisoning.
3.5. Instructional methods
The system gives players feedback in two ways: immediate real-time
feedback and post-event feedback. For immediate feedback, except for
S. Lu et al.
Fig. 5. Scenarios of the storyline (a. Detect the hazards; b. Eliminate the hazards; c. Wear PPE; d. Use the rescue system; e. Wear disposable respirators for personnel;
f. Bind personnel to the rescue system; g. Evacuate quickly; h. Cardiac arrest detection; i. Perform CPR; j. Use AED).
Fig. 6. Error-consequence mechanism (Explosion).
scenarios in stage 1, the system will relay prompts when the player has
not followed the procedure correctly or has selected the wrong option or
approach. For post-event feedback, when the entire drill has been
completed, the rescue personnel receive a detailed overall game sum­
mary, which includes a review of the player’s performance in the drill.
The system also includes a video playback to help personnel review the
entire rescue process.
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Advanced Engineering Informatics 51 (2022) 101520
4. Methods
4.1. Study design and participants
We conducted a comparative experiment at the Pineapple Volunteer
Emergency Rescue Center (Pineapple Rescue), the most prominent so­
cial welfare rescue organization in City H. With the development of
electronic technology and the impact of COVID-19, electronic class­
rooms have shown their potential to become the primary learning
method in training due to the advantage of not being affected by the
constraints of time and place. Relevant studies have shown that the
knowledge dissemination efficacy of this method is similar to that of
classroom training and is often better than VR teaching [46]. Due to the
high efficiency, portability, and low cost of E-lecture, China’s safety
training, especially confined space rescue training, mainly adopts this
approach.
However, to our limited knowledge, there has been no study that
compares the effect of this training method against IVR SG for emer­
gency rescue. To compare the effectiveness of the two methods in
confined space rescue exercises, this article sets up two experimental
groups: IVR SG and E-lecture. We also set the hazard source in confined
space as H2S, which is a flammable, explosive, and toxic gas.
We recruited 32 healthy men aged 21–38 years to participate in the
trial through posters, emails, and phone calls. We informed them of the
nature of the experiment and collected the personal details of the par­
ticipants through electronic questionnaires. Among those recruited, ten
withdrew due to acrophobia, claustrophobia, or otherwise feeling un­
willing or unable to participate in the simulation test. After recruitment,
another facilitator, who was not involved with recruiting the personnel,
randomly divided the remaining participants into two groups based on
the self-reported information that the participants provided. One group
S. Lu et al. Advanced Engineering Informatics 51 (2022) 101520

was assigned to the IVR SG training system, and the other was assigned
to E-lecture training. Details of the two groups are shown in Table 2. A
Mann-Whitney U test was used to compare the characteristics of the two
groups of people, and no significant difference between them was found.
Before the start of the study, the research protocol included the
definition of primary and secondary results, and the statistical analysis
plan was approved by the Ethics Committee of Tsinghua University.

4.2. IVR SG

The IVR SG training was conducted using the system we built called
“Rescue Success.” The system was designed and developed to teach the
rescuer the procedures and operations of confined space rescue. We set
the scenario that the personnel is trapped at the bottom of the well, and
self-rescue and non-entry rescue methods have already failed. Therefore,
the entry into confined space with H2S is necessary. Participants were
supposed to follow the system’s instructions to complete three stages of
confined space rescue: rescue preparation, rescue actions, and life-
saving first-aid. In rescue preparation, the system only gives overall
instructions and does not force the person to complete the corresponding
operations in order fully. In this way, participants correct their actions
by making mistakes and perceiving severe consequences (see Section
3.4). In the rescue action and life-saving first-aid phase, the system gives
corresponding guidance at every step. Participants can learn by prac­
ticing every behavior.
We used the Oculus Quest2 device to visualize the virtual environ­
ment. It comes with a headset and two controllers.
4.3. E-lecture
The traditional training method was implemented using the Tencent
Video APP, as shown in Fig. 7. Participants watched E-lecture courses
recorded by confined space experts via a 15.6′′ laptop screen. The course
introduced the procedure and recommended best practices for a
confined space rescue (see Fig. 1). The contents of the E-lecture are fully
consistent with IVR SG. It was selected for comparison in this research as
it is widely used in confined space rescue training in China, and it is easy
to be understood by participants through its vivid animations and
simulated sound effect.
4.4. Outcomes
The following metrics are considered in our experiment:
(1) Confined space rescue behavior
(2) Procedural knowledge acquisition
(3) Simulator sickness
(4) Self-efficacy
(5) System design
(1) Confined space rescue behavior (Primary outcome)
We used the real confined space site as the test venue for the
personnel to complete the rescue, and the primary outcome was the
Table 2
Basic Information Form.
Fig. 7. The E-lecture on confined space rescue.
performance of participants during the rescue test. The participants are
required to conduct a rescue based on the recommended behavioral
skills (see Table 1). The scores are given basedon the participant’s be­
haviors. The behavior scores ranged between 0 and 10(1 point was given
for each correct behavior and 0 point otherwise). To ensure the reli­
ability of the measurements, scores were given by two experimenters
with expertise in confined space rescue. The cohen’s kappa was 0.90
which indicated a very good level of agreement.
Considering the safety issues, if the participants do not know what to
do, or if they encounter problems, they can ask the supervisor for help,
but doing so will reduce the corresponding behavioral scores. If the
number of help requests exceeds three, it is considered that the rescue
cannot be completed, and the remaining uncompleted scores will be
excluded.
The experimenter will assist the participants with wearing the
emergency rescue equipment as in an actual emergency response. In the
Life-saving first aid stage, we used a CPR trainer to monitor the fre­
quency of chest compressions, and we also used an AED trainer (KS/
AED890) to simulate the operation of the AED.
(2) Knowledge acquisition
We measured knowledge acquisition by using an open-ended pro­
cedural knowledge questionnaire (PKQ), as shown in Table 3. The PKQ
is a simplified version of the questionnaire (range 0–30 with higher
scores indicating higher procedural knowledge) [2]. The open-ended
questions were checked by two experimenters.
(3) Other outcomes
Other outcomes included the General Self-Efficacy Scale (GSE) to
measure the self-efficacy of personnel (range 0–40 with higher scores
indicating higher self-efficacy) [47],the System Design Assessment
Table 3
Procedural knowledge questionnaire.
Questions Score standard

IVR SG (n = 11) E-lecture (n = 11) Q1: What needs to be done before Detect hazards, eliminate hazards, and wear
entry? PPE. (3 points for each, 10 points for three
Age 26.4 (3.27278) 28.0 (4.49242) correct answers).
BMI 21.85 (1.956) 22.15 (2.82910) Q2: What needs to be done from Wear disposable respirators for personnel,
Confined Space Related training 0 0 entering a confined space to bind personnel to the rescue system, and
Education – – leaving? evacuate quickly. (3 points for each, 10
None or primary – – points for three correct answers).
Secondary – – Q3: What needs to be done after Cardiac arrest detection, perform CPR, and
Postsecondary 11 11 leaving confined space? use AED (3 points for each, 10 points for
three correct answers).
Data are numbers of participants or mean (SD/percentages).

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Questionnaire (SDAQ) was used to evaluate the system design (every

aspect of the system design scores − 3 to 3) [2], and the Simulation
Sickness Questionnaire (SSQ) to measure any adverse effects of these
training methods (range 0–64 with higher scores indicating higher
simulator sickness)[48]. The SSQ is commonly used to assess simulator
sickness but not in the context of anxiety treatment. We used a simple
raw score of whether the symptom was present or not. The data were
processed separately and checked by two experimenters.

4.5. Procedure

As shown in Fig. 8, before the start of the study, the experimenter

verified the inclusion and exclusion criteria again. Then the participants
were asked to fill out the PKQ, and GSE as a baseline, and then the two
groups convened separately. For the IVR SG group, we used the Rescue
Success software (see Section 2). The participants used Rescue Success in
a separate 10 * 10 m room after learning the interactive operation of the
software. Participants in the E-lecture group used a 15.6-inch notebook
in the same room to watch the recorded E-lecture course conducted by a
confined space rescue expert (see Section 4.2). The trainees could watch
Fig. 9. Behavioral skill acquisition scores in the real-life rescue exercise.
repeatedly or adjust the viewing speed according to their own needs.
The intervention time for both groups was 40 min. Then the participants
were asked to fill out the PKQ, GSE, and SSQ questionnaires again as the of procedures into effective actions and that IVR SG is more effective
test results. The IVR SG group also completed the SDAQ. than traditional safety training. The observed rescue error behavior is
We reproduced a sewage dredging operation accident site with shown in Table 4, which shows that the errors made by personnel in the
appropriate emergency rescue equipment placed at the site. After the IVR SG group in each recommended behavioral skill are generally equal
training session, the participants were individually taken to the exper­ to or less than that of the E-lecture group.
imental site to complete the test. The facilitator scored the behavioral As shown in Fig. 9, in the rescue preparation stage, the IVR SG group
skill performance of the personnel. During the experiment, personnel was significantly better at gaining behavioral skills than those in the E-
could suspend the exercise at any time, and the remaining unfinished lecture group (p = 0.028 < 0.05). According to Table 4, using the IVR SG
part would be assigned zero points. Finally, we conducted interviews based on learning by mistake theory, the IVR SG group performed well
and inspections with the participants and ended the experiment after in detecting and eliminating hazards, with no errors. Meanwhile, 36% of
confirming that the staff had no adverse reactions. the E-lecture team made mistakes. In addition, the number of people in
the IVR SG group incorrectly carrying safety protection equipment is
also significantly lower than in the E-lecture group. These results indi­
5. Results and discussion
cate that the IVR SG training, based on learning by mistake theory, is
more effective than E-lecture training. We can thus infer that this
5.1. Behavioral skills
method can help avoid blind rescue situations because it makes
personnel aware of the severe consequences of mistakes in this haz­
This section will discuss participants’ behaviors in the experiment’s
ardous environment. In this way, rescuers can enhance their awareness
rescue preparation, rescue action, and life-saving first aid stages and
of their own safety protection and be fully prepared (detect and elimi­
divide the observations into two phases to analyze their performance
nate hazards, self-protection), so they will not suffer a life-threatening
pre-and post-training. All participants performed rescue in a real utility
accident (e.g., explosion, poisoning, drowning) [1].
hole. A Mann Whitney U test was then used to compare the differences in
In the process of taking rescue action, the score of behavioral skills
behavior manifested by the two experimental groups observed at the
acquisition of the two groups did not differ significantly (p = 0.094 >
different stages.
0.05), and both groups of people made very few mistakes in using the
As shown in Fig. 9, the overall performance of the IVR SG group in
towing system and rapid evacuation. This is consistent with the actual
the real-life exercise was significantly better than that of the E-lecture
situation that on-site rescuers generally have no problem using the
group after the drill (p = 0.002 < 0.05). Consistent with previous studies
towing system to enter the confined space when an accident happens.
[9,27], our results show that both methods can transform the knowledge

Fig. 8. Flowchart of the experiment.

7
S. Lu et al. Advanced Engineering Informatics 51 (2022) 101520

Table 4
Errors made by the two groups.
Stages Recommended Behavioral Practice Error Description Practice (E- Error Description
Skill (IVR SG) lecture)

Rescue Detect the hazards 0 None 3 Skip

preparation Eliminate the hazards 0 None 1 Skip
Wear Personal protective 2 Carry nonexplosion-proof mobile phones; 6 Carry nonexplosion-proof mobile phones;
equipment skip some protective equipment skip some protective equipment
Rescue Action Use the rescue system 0 None 0 None
Wear disposable respirators 3 Skip 7 Skip
for personnel
Bind personnel to the rescue 0 None 0 None
system
Evacuate quickly 1 Stay 1 Stay
Life-saving first Cardiac arrest detection 3 Skip 2 Skip
aid (BLS) Perform CPR 2 Perform artificial respiration 6 Perform artificial respiration
Use AED 1 Skip 7 Skip

Moreover, according to Table 4, seven people in the E-lecture group
neglected to offer protection to the trapped entrant, while only three
people in the IVR SG group made the same mistake. This may be
explained by noting that people trained in VR can follow the procedure
and complete tasks in a challenging emergency environment [27].
In the lifesaving first aid stage, the behavioral performance of the
IVR SG group was significantly better than that of the E-lecture group (p
= 0.014 < 0.05). Moreover, the results show that after training, IVR SG-
trained personnel can better complete the operations of CPR and AED. In
terms of CPR, fewer people in the IVR SG group have done it wrongly by
giving artificial respiration to poisoned persons or skipping related op­
erations. In terms of CPR quality, we considered 100–120 chest
compression per minute recommended by the ECC & CPR guideline
2020 to be high-quality compression [39]. As shown in Fig. 10, only two
people in the E-lecture group had the correct average compression fre­
quency, while eight people in the IVR SG group performed it correctly.
This demonstrates that IVR SG training can help people better master
behavioral skills and improve the quality of a skill (e.g., CPR) compared
with an E-lecture. A possible explanation is that the trainee’s repeated
exercises in the virtual environment deepen the memory and proficiency
of their actions. VR training of first aid in emergencies is rarely
mentioned in previous studies, and the current research results help to
address this knowledge gap.
5.2. Knowledge acquisition
We performed a Mann-Whitney U test on the data of the two groups
in procedural knowledge acquisition, and we found that those in the IVR
SG group were significantly better than those in the E-lecture group in
terms of learning procedural knowledge (p = 0.027 < 0.05). Here, the
level of procedural knowledge of the two groups showed a significant
improvement (p < 0.001), while there was no significant difference in
the knowledge level of the two groups of people before learning (p =
0.563 > 0.05).
These results are similar to previous studies, which showed that VR
training is highly effective for procedural knowledge training [49–51].
Moreover, we found that the personnel’s procedural knowledge score
and behavioral performance score are positively correlated.
5.3. Other secondary results
As shown after the paired-sample T-test, both the IVR SG and E-
lecture groups significantly improved self-efficacy after training (p <
0.001). Moreover, the improvement in self-efficacy of personnel trained
using IVR SG is significantly better than that of the personnel trained
using E-lecture (p < 0.001), while the self-efficacy score and the per­
sonnel’s behavioral performance score are positively correlated. Ac­
cording to the Mann-Whitney U test, there is no difference between the
two groups with side effects (p = 0.446 > 0.05). The reported side effects
of both groups are mild except for one person in the IVR SG group who
experienced severe side effects such as dizziness (eye open) and fatigue,
which indicates that the use of IVR SG technology may not be suitable
for a small number of people because of sickness. Finally, 22 people from
the two groups were invited to rate the system design. As shown in
Fig. 11, we found that the five assessment components of the system
performed very well (scores all above 2).

Fig. 10. The number of people with the correct average compres­
sion frequency. Fig. 11. Component assessment of Rescue Success.

8
S. Lu et al.
6. Conclusion
The main goal of the current study is to offer an efficient training
method to transfer standard rescue procedures to confined space res­
cuers to avoid blind rescue situations, which are the cause of the failure
of many confined space rescues, commonly leading to severe casualties.
A confined space rescue training system is developed based on IVR SG
called Rescue Success. Highly realistic environment design and inter­
action technologies such as personnel positioning and motion capture
enhance the realism of the virtual environment, which helps behaviors
and knowledge learning. Moreover, design based on learning by mistake
theory is introduced in safety training using IVR SG and the error-
consequence feedback mechanism based on FTA in IVR SG is proposed
to emphasize errors’ severe consequences during a rescue. In order to
test the effectiveness of our system, we conducted a randomized com­
parison test to compare the system with the traditional safety education
method of E-lecture and tested the learning effect in a real confined
space site. Our experimental results prove that IVR SG training can be
used in confined space rescue emergency drills and is more effective
than E-lecture training.
There are some limitations to this article. We only conducted
research on sewer hole rescue training and simulated the hazard sources
of hydrogen sulfide and rising sewage. However, there are many other
hazards, and more types of accidents may happen in confined spaces.
Rescue time is a crucial validation aspect in rescue drills, which was not
considered in our experiment that focused on evaluation immediately
after training. We will consider more types of simulated hazards in our
future research and use the fault tree analysis method to simulate more
types of accidents to enrich our training system, which will also be
shared in an open-source format. Lastly, more participants will be
invited to further verify the training effect of rescuers over a longer
period.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
This research is supported by the Science, Technology, and Innova­
tion Commission of Shenzhen City, China (Grant Number:
JCYJ20180508152055235), and the Science and Technology Depart­
ment of Guangdong Province, China (Grant Number:
2019B111104001).
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