Watch what you say...

The title of this blog might appear to be a bit strong, but consider the following:

• The man dropped the vase, and it broke.
• The vase broke when it was dropped by the man.

The first sentence puts the action (or agency) on the man, on the ‘who’ was involved, whereas the second statement focuses on the vase. This second approach makes it easier to ask the question ‘What happened?’ or ‘How did it happen?’. Because the former statement focuses on an individual, there is a tendency to look at their behaviour, skills, and attitudes, and we fall foul of the Fundamental Attribution Error. This is where we look at the individual and their skills, attitudes, and behaviours as the cause of the event, rather than looking at the context – how did it make sense for them to do what they did.

Running out of gas...

In a more complete situation, like the following where a diver ran out of gas, which of the following two stories is more likely to explain the rationale of the divers involved? 

I was a diver on a day boat. We had already completed one dive on the wreck and we were planning on a similar second dive on the same wreck. I was diving with twin 80s and the wreck was in 100ft/30m. The cylinders were not topped up between dives as there wasn't a compressor onboard. We briefed the second dive and what we planned to do, including swimming into the superstructure of the wreck. During the second dive, I struggled with getting onto the anchor line and down to the wreck. On arrival at the wreck, I checked my SPG and noted that I didn't have much gas, not enough for the planned dive. The current was stronger than expected too. I didn't say anything immediately, and before I could signal them, my buddy swam off into the superstructure of the wreck to explore. I chased them down and signalled that we needed to ascend as I was nearly out of gas. We got back to the anchor just as my regulator went tight and I then did a gas-sharing ascent to the surface with my buddy. We didn't tell anyone what had happened.

Or this second one? 

I was a diver on a day boat. This was the first time I had dived with my close friend for a while. I had just finished a cave class in Florida and it was great to get out on a boat and dive this large wreck. We had already completed one dive in good visibility and there was no current and were planning on a similar second dive on the same wreck. I was diving with twin 80s and the wreck was in 100ft/30m. This was different to the recent cave diving class where I was diving HP130s (twin 16s). The cylinders were not topped up between dives as there wasn't a compressor onboard. We briefed the second dive and what we planned to do, including swimming into the superstructure of the wreck. As I entered the water for the second dive, I noticed that the current was much stronger, and I struggled with getting onto the anchor line and then down to the wreck, almost like a flag on a pole. As we got to the bottom, I checked my SPG and noted that I only had 1000psi/70 bar which wasn't enough for the planned dive as the minimum gas needed was 750psi/50 bar (only 300psi/20 bar to complete the dive). The current was much stronger than this morning's dive. While I was checking my gas, my buddy swam off to the superstructure to get out of the current and start the penetration. In the bright light, I couldn't signal effectively. I chased them down and had to make an immediate decision - enter the wreck and get my buddy or do a solo ascent with low gas in a high current. I signalled my buddy in the dark corridor and they immediately turned and we returned to the anchor line. As we got back to the anchor, my regulator went tight and then we did a gas-sharing ascent to the surface. On the surface, we talked through all of the critical factors that lead to this event including inferred peer pressure, changing conditions in the water, not recognising the impact of high current, the small cylinders between ocean diving and cave diving, not acting as a team at the bottom to ensure we were both ok before setting off into the wreck, not checking before entering the wreck, much of this was something that an effective brief would cover. We also talked about the positive aspects of the gas-sharing ascent and how previous practice and experience made that emergency less eventful. We didn't tell anyone on the boat about what happened because the mistake was 'obvious' and 'stupid'.

The story is the same, but there are different words used to describe what happened. There is more context, and it is the context which shapes our understanding of the event and how it made sense for the divers to behave in the manner they did – note this is THEIR behaviour, not how YOU think YOU’D behave. The focus in the second narrative has moved from an individual’s failure to plan their dive effectively, monitor their gas while on it, and then tell their buddy there was an issue, to one in which the decision-making process can be seen to be shaped by the context in which the diver found themselves. They missed information at the time, but we miss information all the time. It is only after the event that we can see how significant something was.

How we present the story...

How we present information to people so that they can understand and then comment or judge on the event is therefore critical.

Research from 2018 showed that when a simple, linear-cause-and-effect incident report, created by combining multiple statements into a single narrative, is provided to safety professionals to pass comments on the lessons learned and their judgement of the event, the comments were heavily biased towards individual retraining and punishment. However, when the same account was described by providing multiple accounts from all of those involved, with the narratives highlighting the competing goals, organisational pressures, and lack of resources, the feedback from a similarly trained group of individuals was focused further up the organisational system and didn’t include any punitive action.

It isn’t just about how the information is presented to the reader, the assessments and judgements are also based on how much knowledge the individuals who read reports have about how safety (and failure) are created within a system. Research from 2023 has shown that highly experienced pilots are more likely to look at systemic issues whereas low-experience pilots look at individual failures and lack of compliance rather than the wider system when presented with the same incident reports to review.

The availability of context-rich narratives is limited when it comes to diving near-misses, incidents, and accidents. There are a number of reasons for this and this is being explored as part of a research project I am leading. One of the reasons might be that divers don’t know how to tell a learning-based story because they haven’t been taught. 

Sports diving and associated training programmes predominantly come from Western cultures. Safety protocols and compliance are often based on Western cultures too. This means that the language is heavily biased towards human-focused agency (man dropped the vase, not the vase was dropped). So, the rules, guidance, and investigation protocols are wired towards looking for the individual who is at fault. If you are diving or working in an environment which focuses on individual blame, and you are asked to provide an account, the account will likely be written in a manner which doesn’t look at the context (trade-offs, pressures, flawed rules, conflicting goals etc) but rather will tend to look at individual behaviours, attitudes, and skills of those involved.

Look at the reports you find online and see how many consider the context and the error-producing conditions that WILL be present. How many focus on the immediate (proximal) causes? How many of them take a look further back in time to see how the knowledge and skills of those involved have developed and therefore shaped the current decisions? How many consider ‘how it made sense’ for the divers to do what they did?

What goes into a report?

Another thing to consider is the length of the incident account. How many of the reports that people make are short, brief narratives? How many of them are context-rich, and therefore longer? The second account (above) is over twice as long as the first! People like to be as efficient as possible (System 1) and so write a short narrative, but in the case of learning, we have to slow down and engage System 2, and provide an account with enough detail so that someone can read it and say “Yes, I can see how that would happen.” even if you don’t agree that it was a sensible thing to do.

This video from a graduate at Loughborough University brings this perspective to life in a vivid 10-min video and takes two contrasting views of the loss of the SEWOL ferry with the loss of 295 passengers, of which 246 were children.

Two Contrasting Views of the South Korea Ferry Accident - English from MAN PARK on Vimeo.

You might not agree with what happened, and you might want to still blame the captain involved, that is fine. At the same time, this video shows how complex interactions within a multi-faceted system can lead to a large loss of life.

This graphic shows how the use of the negative leads to failure, rather than examining the context. How many times have you seen 'lack of...' without an understanding of why it wasn't possible to address the issues? How much training and experience did people have? What causes the pressures that were present? Were there any conflicting goals? It isn't just the reports that contain this language, the guidance documents on how to complete an investigation are full of these statements as causes of accidents/incidents. 

Summary

If we want to change our attitude towards failures, near-misses, incidents, and accidents in diving, we must change the language we use. We must move from an individual-blame focused approach to one which looks at the wider system, the relationships within it, and the context in which divers and instructors are operating. This context needs to capture competing goals, limited resources (time, equipment, money), what does ‘normal’ look like, how risk is managed (4Ts) and what happens when adverse events have occurred in the past. Unfortunately, the guidance that is available is very much written to focus on non-compliance and deviation rather than local rationality and what ‘normal’ looks like. The Human Diver has a “Learning from Unintended Outcomes” course, the next edition starts in September 2023 and between now and then, I will be writing a comprehensive guide on moving from blame to learning using an HF and system-learning approach.

Gareth Lock is the owner of The Human Diver, a niche company focused on educating and developing divers, instructors and related teams to be high-performing. If you'd like to deepen your diving experience, consider taking the online introduction course which will change your attitude towards diving because safety is your perception, visit the website.