Why ‘They should have’, ‘...could have’ or ‘I would have..’ do not improve diving safety

When things go wrong, or incidents/accidents happen, it is easy to identify how the problem could have been prevented by applying one of the following the phrases ‘If only they’d done A…’ or ‘They should have done B…’ or ‘They could have done C…’ or ‘I would have done D…’ We do this because we are trying to identify a way in which we could prevent the same thing happening again in the future.

This is a natural reaction. We are trying to bring order to disorder and is known as counterfactual reasoning. At its most basic form, we think that if the people had taken different actions, then the outcome would have been different. Unfortunately, we are applying non-existent facts to the story to tell a different one, one with a happy ending.

Here are a couple of examples of counterfactuals in relation to diving:

  • If the rebreather diver had done his checklist properly, then he wouldn’t have entered the...
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'Choices': Guaranteed small loss or a probable larger loss, injury or fatality?

You have been blown-out for 4 weekends in a row and you now have an opportunity to dive this weekend as the weather is fabulous and the visibility has been reported as 10m+. However, you aren’t due to dive for another four weeks for a variety of reasons. Just as you getting your gear ready to put on, you notice that you have a malfunction with your gear, something manageable but will cause you additional workload and reduce your margin of safety on the dive. This is a failure you wouldn’t normally accept because you get to dive lots. If you don’t dive, your buddy will have to sit out too as there isn’t anybody else to dive with them at such short notice. What do you do?

At this point, you are managing uncertainty not a risk because the numbers are not calculable. You decide to dive and nothing adverse happens and you have an awesome dive.

Are you reflective of your management of uncertainty? Did you think it was ‘good’?

But what if two or three...

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Dive safety leads to nothingness...and nothingness is unemotive!

How safe are you when you dive and how do you measure safety? Think about the following story and how safe the situation was...

Six divers had decided to undertake a 30m dive from a RHIB. John and Dave were diving as a team with their local university dive club and had over 2000 dives between them. Graham was relatively newly trained as a marshal and had not worked with Brian before. On the dive boat, there were two new divers to the club, Gail and Mark. Both Gail and Mark had successfully completed a check-out dive & dry suit familiarisation course with another instructor in the club, and they were already certified for 40m diving. Graham was keen to do a drift dive in 32m of water. Brian, the cox, was somewhat worried about the conditions as there seemed to be waves forming. However, as long as all divers were certified to 30m diving and effective at getting into the water and back onto the RHIB, he was happy that the risk was acceptable. To allow the Cox and Marshall to...

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Why ‘everyone is responsible for their own risk-based decisions’ isn’t the right approach to take to improve diving safety.

A diver qualified in the summer of 1999 while on holiday in Greece. His final dive on his PADI Open Water course was to 25m, obviously beyond the standards of this course. The instructor told him to write 18m in his logbook as they were only supposed to go to 18m. The diver didn’t know this during the dive so didn’t question the depth they dived to. Nor did they know that there was a way of providing feedback to the agency for breach of standards. In March 2005, the diver went to Cape Town with work and there was an opportunity to dive at Gansbaai so he took his OW card with him. He hadn’t dived since his OW course in 1999. There was no checking of cert cards when they got there, nor was there a skills dive to ensure everything was ok. The diver and 3 of his buddies completed a 45min 10m dive from a RHIB with no problems.

One month later the diver was in San Diego, again with work, and wanted to go diving. He had decided that one of the most important things he...

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Cognitive Dissonance - Why you are right and I am wrong...Or are you?

"A man with a conviction is a hard man to change. Tell him you disagree and he turns away. Show him facts or figures and he questions your sources. Appeal to logic and he fails to see your point." -  Leon Festinger

Cognitive Dissonance has been defined as the psychological pain of accepting facts which are counter to our views which then prevents an open and rational cycle of improvement.

Recently I re-read Black Box Thinking by Matthew Syed (a book I’d thoroughly recommend). The book uses aviation safety as the premise for improving patient safety by looking at the ways in which data has improved the former - the data from aircraft black boxes and cockpit voice recorders showed investigators what the pilots saw and experienced and how it could have made sense to them at the time, despite what hindsight bias and outcome bias would them to believe. Furthermore, data from the aircraft systems would allow reconstructions to take place in the simulator to see lessons...

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'Entirely Predictable' vs 'Managing Uncertainty': How many rolls on the dice?

decision making risk Jul 22, 2018

A couple of social media posts about diving incidents and near misses have triggered this blog because the term ‘entirely predictable outcome’ has been used to highlight that someone shouldn’t have done what they did because it was obvious that it would end up with an injury or death. The problem is that such statements, as they applied to those particular situations, are false, even when the commentators are biased because of hindsight.

To explore this, let's look at the dictionary definitions of ‘entirely predictable’. Entirely means ‘completely’ or ‘to the full extent’ and predictable means ‘always behaving or occurring in the same way as expected’. So entirely predictable means that on 100% of occasions the outcome would be as it was experienced in the particular occasions. If this was true, people would not do things which ended up with them injured or dead (unless they truly had suicidal tendencies, and those...

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Blood, Banks and Diving: The value of knowledge, experience and training

The body contains millions of cells, a fraction of which are blood cells. Those cells are broadly split into two types, red blood cells for carrying nutrients and oxygen to the tissues and recovering the waste and CO2 for disposal, and white blood cells which are used to fight ‘bad stuff’ that is in our bodies such as germs and viruses. They both have their purpose but their contribution to the productivity of the human body is somewhat skewed.

By that I mean if we were to look at their productivity over an average year, the red blood cells are really productive, they are used all the time and they support the body’s needs on a second-by-second, minute-by-minute basis. If we stopped the flow of oxygen to the tissues by preventing oxygen being picked up e.g. carbon monoxide poisoning, then the tissues would die relatively quickly. Compare that to the white blood cells, which are primarily used when an infection or anti-body is detected and the body responds by...

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Why did he make such an obvious mistake...?

Recently there have been a number of high profile incidents in diving in which the decisions made appear incredulous given the outcome. Using a phrase from Todd Conklin, a US-based high performance team developer and safety advocate, the outcomes whilst sad in many cases are not the most interesting part, it is the decision making process which led to them which is interesting. You could say that they are unsurprising or normal. In fact, in 1984 Chris Perrow wrote a book entitled ‘Normal Accidents’ in which he describes the facts that most of accidents in high risk operations are normal, in that we know they could happen, we just don’t know where and when, and given our limited personal and organisational capacity to process massive amounts of information, it is no surprise that they slip by our attention and we make flawed decisions. It is this combination of, often discrete decisions which leads to disaster.

That is what this blog post is about, decision making...

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Local Rationality: Why an old lady vandalised art and how to improve diving safety!

You may be wondering what the vandalism of a piece of art has to do with diving safety and improved personal/team performance, but read on. One of the best ways of getting a point across is by telling a story…and so this story begins.

"An elderly German woman was questioned by police after filling in blank spaces on a crossword puzzle that was being displayed as a work of art at a local museum. The BBC reports that the 91-year-old woman used a ballpoint pen to write on the work of art titled "Reading-work-piece" by avant garde artist Arthur Koepcke during a senior citizens tour to Nuremberg's Neues Museum.” - Link

How could someone be so daft as to write on a piece of art in a museum, surely it was obvious that the exhibit was an exhibit and not something to be interacted with? Maybe it was because she was old and had dementia? Indeed, one news report called it an error but she admitted that she did it on purpose. Using that rationale and your normal thought...

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