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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When the holes line up...

Many of my readers will have heard about me talk about Professor James Reason's Swiss Cheese Model and how it can be used to show how incident develop because of holes in the barriers and defences which are put in place to maximise safety.

Professor Reason's research showed that at different levels within a system, there are different barriers or defences present. e.g. organisational, supervisor and individual. However, these defences can have holes in them because the organisations, supervisors and operators are all fallible and therefore the defences cannot be perfect.

  • At the Organisational level, these failures might be poor organisational culture, inadequate diver and instructor training programmes, flawed equipment certification systems e.g. CE or ISO, or misunderstood/misused reward or punishment systems e.g. QC/QA or certificates for the number of certifications completed.
  • At the Supervisor level, these gaps might be inadequate supervision dealing with inexperienced...
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