Language Matters: An HF Approach to Reviewing an ‘Accident Analysis’

I have been asked a number of times to comment on a 'hypothetical' event published on the RAID website on 7 August 2024 as a learning opportunity. However, it appears that the story wasn’t hypothetical, and the person involved wasn’t directly consulted about what happened. The event had a ‘bad’ outcome and the goal of the ‘analysis’ was to look at the event through the lens of learning. This review is based on a copy of the story which was retrieved on 12 August.

The review is available as a PDF from here as well as the post below. The reason for providing both formats is that I cannot create the same layout in a blog on this website and the images (screenshots of the PDF) aren't as easy to read.

Framing

How we frame learning opportunities and the language we use is critical for two reasons: firstly, we need to create the environment for others to learn by showing the analysis is informed, critical and focused on actions/behaviours, and secondly, because when we focus on the context and the conditions, we create an empathetic response to those involved. Nobody intends to have a ‘bad’ outcome. The best analyses are those where you walk away saying “Yes, I can see how they would have done that given their circumstances” not “I wouldn’t have done it that way because it’s obvious it would go wrong”.

The diving industry has a long way to go to bridge this gap in terms of learning. This isn’t surprising given that with the exception of the work by The Human Diver, there aren’t any training programmes that focus on learning-focused outputs, nor are human factors, psychological safety, and a Just Culture comprehensively taught in diver education programmes.

“The currency of safety is information” – Ivan Pupulidy Ph.D.

If we don’t get the correct information, in the correct frame of reference following an adverse event, then we are not going to be learning very much. We will continue to tell divers and instructors to be more careful, to pay more attention, to be better, to better manage risk, to not lose situation awareness… these statements don’t help learning because they don’t explain how the ‘failure’ occurred.

There are always multiple stories present in an event. In this case, we don’t have detailed responses from the student, the instructor, or the captain of the dive boat. Social media posts are available, but these will only recount the story that wants to be told rather than the context-rich stories which will describe the workarounds, adaptations and modifications that are part of normal 'work' – the current reports don’t explain the local rationality of each of the stakeholders. I would argue that this is because of the culture present in diving, which is often focused on blame rather than learning.

“Blame is the enemy of safety” – Nancy Leveson.

While the published article aimed to create a learning opportunity, the tone at the start is very much framed around ‘they did wrong, can you spot where it went wrong?’ – rather than the learning position which would been focused on what made sense to those involved at the time. If we start to introduce blame, especially if those involved haven’t been part of the conversation, then parties will get defensive and will only state what they want to disclose to protect themselves. This means we, as observers/readers, will fill in the gaps with what we think should have happened. We tell a story that didn’t exist. Note, these biases/concepts also apply to the readers/observers of the original web article – we are filling in gaps because we don’t know what the explicit and implicit goals were.

The quality of reports, even in established environments, varies. If you want to see what a neutral accident report looks like for what is an apparently ‘obvious’ cause behind the grounding of a vessel, visit the Danish Maritime Investigation Board here. Compare this to the report of a $450M B-1B loss from the USAF in January 2024 where you can easily play ‘spot the counterfactual’ in the summary.

Additional Learning Opportunities

The following blogs will help build your knowledge about framing and learning from adverse events. There is no ‘silver bullet’ answer to creating successful outcomes. What is clear from multiple domains, fatalities rarely help learning because the decision-maker is normally dead, emotions are high, and defensive barriers are raised. Therefore, we should focus on those events where there is someone to have a conversation with and where we can understand their local rationality. That can only happen with a shift in paradigm around safety – not the absence of accidents, but the presence of capacities and capabilities that allow us to predict, monitor, adapt and learn during diving operations.

• Roaring River Fatality
• Maltese Diving Fatality
• The role of ‘Agency’ in understanding adverse events.
• Unlocking the Secrets of Safer Diving: A Guide to Learning Reviews in Diving
• It’s obvious why it happened!! (In hindsight)
• Don’t just focus on the Errors – Look at the Conditions 

 
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.