Why is it so hard to talk about failure?

About ten years ago I started up a small section on a UK diving forum (YD then TDF) called “I learned about diving from that…” (ILADFT)  which was based on the RAF Flight Safety magazine section “I learned about flying from that…” where aircrew would write in about their mistakes and close calls and others could learn from them. ILADFT was to be the same. It took a little while to get going, and people would talk about things that went wrong. The basic rule was that negative criticism was banned and posts which ridiculed divers for putting their hands up were stamped on quite quickly; it was the genesis of the ‘Just Culture’ work I have been doing over the years. It was also this that piqued my interested in diving incidents and how to prevent them - the same stories were coming up again and again and yet nothing appeared to be done to talk about them.

Failure...

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Incompetent and Unaware: You don't know what you don't know...

diving human factors safety Apr 28, 2016

This is a summary of my presentation at TekDiveUSA as recordings weren't allowed. The interactive presentation was just short of an hour so this is a bit of a long post!!

The simple premise is that we don’t know what we don’t know. Even worse, we don’t that we don’t know!! This double hit in competency was highlighted by a couple of social researchers Dunning and Kruger when they undertook a series of experiments to assess what their subjects thought of their own knowledge. The exams covered logic, humour, and grammar and showed how prevalent the problem was.

The images below show the issue at hand. Pretty much everyone thought that they were above average (60-70% scores), but not exceptional. However, if you look at those who scored in the bottom quartile, the lowest scores were in the order of 12-15% even though they thought they scored 55-60%. The other noticeable part was that those who were well above average underestimated their abilities. However,...

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It's the little things that catch you out...

Humans like to do things efficiently, or as some call it, cutting corners. The problem is that when the configuration changes and the diver cannot recall the 'situation' and it bites, it sometimes ends up with a dead diver. 

Complacency is a term often used as one of the key factors when it comes to diving fatality reports. The problem is that complacency is only really apparent after the event because we have had something occur that shows us how far we are from the ideal. The same mental developmental processes which allow us to operate efficiently are also the same processes which can lead to an accident. Complacency can be summed up as the difference between the perceived model of the world and the reality of the situation. To save time, humans create models of expectation of what is happening around them so that we don't have to process vast amounts of information. If nothing changes, we run that mental model making assumptions about what will happen in X...

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What relevance does Human Factors have to recreational and technical diving?

A comment I often get is "How relevant is Human Factors to my diving and why should I care? I haven't had an accident so far, so I (we) can't be doing anything too wrong"

This is a fair comment but consider that high risk organisations have learned the hard way: using the premise that evidence from the past to determine behaviours in the future can lead to some very bad outcomes. Consider the following examples:

  • NASA and the Challenger and Columbia disasters - doing the same things and edging further from accepted standards, a normalisation of deviance, aterm coined by Diane Vaughan. That's a pretty big organisation.
  • An Executive Jet crew who forget to remove the gust lock from their jet which meant they couldn't move the control column subsequently crashed at the end of the runway killing all onboard? 
  • A general aviation pilot who didn't drain the water from his fuel tanks as part of the standard operating procedures and crashed? 
  • The students and...
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How Much Are You Willing to Risk?

I have just finished reading a chapter in Daniel Kahneman's "Thinking. Fast and Slow." about decision-making, risk perception and gambling which I thought had some interesting parallels in the world of sport diving, especially given some recent fatalities where comments have been made about crass stupidity or the divers were Darwin Award candidates. As I am very keen to promote Just Culture, which recognises that sometimes we make decisions which appear to be contrary to common sense, I thought I would reproduce some of the arguments/theories here in the blog. Feel free to post/share wherever and like this blog.

The premise is based on the following three questions which are lifted from the book.

Problem 1: You are offered a gamble on the toss of a coin. If the coin shows tails, you lose 100. If the coin shows heads, you win 150.

Is this gamble attractive? Would you accept it? To make this choice, you must balance the psychological benefit of getting 150 against the psychological cost...

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