Bad Things Happen to 'Bad' People: Meet the Bogeyman.
When a diver dies or has a serious adverse event, the first thing most of us (online) want to know is what they did wrong. Not deliberately, and not out of malice. We read the report, or more often the thread underneath it, looking for the decision that separates them from us.
They were diving beyond their training.
They had skipped a check.
They were solo.
Overweighted.
On a mix they had not planned properly.
Once we find it, our concern settles, and we go back to our own planning and life, with the quiet sense that we would not have done that.
Leonie Boskeljon-Horst focused on that response in her professional domain - not diving, but aviation. She spent more than twenty years as an aviation psychologist in the Royal Netherlands Air Force, and wrote her doctoral thesis about why her own organisation kept failing to get safer despite trying hard.
She called it The Bogeyman Unveiled.
The bogeyman she found was not a person, rather it was a belief, held by everyone through the organisation, that compliance equals safety, and behind it a message that wasn't written down anywhere but everybody had heard. Bad things happen to bad people. If you do not follow the rules, something bad will happen to you.
Sound familiar?
Measuring safe is not the same as being safe
The first study in her thesis is worth pulling out on its own. A helicopter squadron took part in a safety culture assessment, the kind that places a unit on a 'maturity' ladder running from pathological up through reactive, calculative and proactive to generative (the image describes what each of these layers means). Three weeks after the survey had been completed, one of its aircraft struck a light stand with its rotor blades while taxiing, and an independent investigation happened, and a report was produced. Because of her role, Boskeljon-Horst and her colleagues were able to put the two documents side by side and compare them.
They described different squadrons.
On most indicators the crews had rated themselves near the top of the ladder, and the investigation found behaviour several rungs lower. On one indicator the result was worse than a mismatch. Empowerment came out as generative, meaning the crews believed they were trusted to use their judgement, and the investigation then listed that same empowerment among the things that produced the accident. The crew judged the marshalled parking spot too tight, parked without the marshaller, and made a series of reasonable local decisions about clearance that ended up with the rotor colliding with the light stand. Openness had been rated highly too. During the taxi the copilot saw the light post, decided it fell outside the minimum obstacle distance, and so said nothing.
Three weeks is not long enough for a culture to change, so one of these descriptions was not describing the squadron. The culture assessment recorded how people believed their work went. The investigation recorded how it actually went on one afternoon. The authors concluded that a maturity assessment offers little protection, and may offer worse than nothing, because a good score invites the organisation to tick the box and stop looking.
Diving is full of the same example and instruments, but in different clothing. The quality assurance questionnaire that goes back to the agency, the end-of-course feedback form, the audit confirming that ratios were met, the centre that has run for twenty years without a serious incident and says so on its website.
Each of these describes the paperwork or the perception, and none of them really measures how the work is done on a busy Saturday with a boat to catch.
A clean record can mean the operation is well run. It can also mean nobody has looked hard, or that the margins have been eroding for years and the weather has been kind. From the inside those two situations feel identical. Compliance provides an illusion of safety...
The promise is what counts
Given the above, you might wonder why organisations keep reaching for these measures. It is because they need something to show. The Dutch Ministry of Defence is a political instrument, and it needs budget and public support. Not unusually, like many MoDs, it had spent a decade absorbing cuts while being asked to deliver the same output. So it made a promise: we comply. As Boskeljon-Horst puts it, compliance itself is not the important part. The promise of compliance is.
Diving has the same structure but without the parliament. Agency standards are what the industry shows to insurers, to lawyers, to families and to anyone thinking about a course. When an incident becomes public, the first question asked of the operation is whether standards were met, and the first thing it wants to be able to say is yes. A recent blog looked at why complying to standards doesn't mean an operation is actually safe.
That promise then has to be kept in a world it does not fit. Boskeljon-Horst's aircrews were dealing with rules written elsewhere by people who had not flown operationally in ten or fifteen years, rules that in some cases made the job harder or the flight less safe. So they adapted. In her earlier work she called these adaptations local ingenuity, and she was careful about the word. Local ingenuity is an expression of expertise, care and professional judgement, applied where the written rule does not reach.
Diving instructors do this constantly. The skill sequence gets reordered because the viz dropped and the group is cold. The extra session for the student who is not ready happens on a Sunday morning that nobody is paying for. The brief gets shortened because the weather or tidal window is closing. A club dive gets planned around who is available rather than around who the rules say should be there. None of this is about negligence or being careless. It is people using what they know to hold together an operation that would otherwise stop.
What the aircrews would not do is write any of it down. What they feared most was not the accident but being held personally liable for it, and their sense that there was no just culture to fall back on made that worse. Any instructor who has decided not to log something has made the same calculation. My MSc research had a number of such examples.
The gradient of what can be said
Everyone in the air force knew this was happening, and the willingness to say so out loud declined the further up you went. Operators talked openly about adapting. Senior officers acknowledged the need to get the job done while also insisting on compliance, apparently without noticing the contradiction. At the top the promise to the government and the public stood untouched. Management, in the middle, has to either quietly condone the adaptation or avoid becoming curious about how the work is done. Wilful blindness...
Diving has the same gradient. Instructors know what they change and why. Course directors and centre owners half know, and mostly do not ask. Agencies cannot know, because knowing would mean saying publicly that their standards do not always fit the conditions their instructors work in. So the adaptation stays local and invisible. That means it never gets examined, never gets improved, and never feeds back into the standard that produced the need for it. Again, another finding from my research. The feedback system is broken.
Just like Columbo, there is one more twist! Most rule sets allow the professional to deviate where safety requires it, and diving standards are no different. Boskeljon-Horst points out the fallacy in that. The permission comes attached to an expectation that you will justify the deviation afterwards. If other experts, reviewing it later and knowing how it turned out, decide the deviation was unnecessary, the exercise of operational expert judgement is now relabelled as a violation. The discretion is real right up to the moment it is tested, and then it is not.
What the bogeyman protects
This is where the two halves meet. If bad outcomes are caused by people who failed to comply, then the assessment that rated the operation as mature was correct. The score remains and the individual is the subject of the investigation, and each event gets explained by someone else's failure. For everyone else, it means something much simpler. If bad things happen to bad divers, then careful divers are safe, and I am careful.
In bogeyman stories the consequences for the professional are never spelled out. Nobody can say exactly what happens if you are found non-compliant. Instead, what people have is the occasional visible sacrifice, the resignation or the disciplinary case, which keeps the fear alive without defining it. The fear of litigation in diving is a classic example of this.
The cost is that the information the industry most needs to make improvements never becomes available. If bad things happen to bad people, admitting you adapted is admitting you might be one of them. Near misses go unreported, workarounds stay private, and the standards that made the workaround necessary carry on producing the same pressure for everyone else. As Clive Lloyd said, "You can't fix a secret."
What can be done instead
Leonie's main proposal is a change in policy rather than a change in behaviour. She points to the United States Forest Service, which moved overnight from prescriptive rules to guidelines - I wrote about this in 2017!. No new rules were written, but three things did happen.
The existing rule base was reinterpreted so that the judgement of the person doing the work took precedence over instructions written a long way from it,
Changes to how incidents were investigated occurred.
How leaders were trained to deal with uncertainty and ambiguity, and how to respond to events.
Diving cannot do that centrally, but any centre or club can do a version of it. Stop asking people to provide a score about how they think the operation runs, and start asking them what they change and why, and what gets in way of doing a good (correct) job, and then treat the answer as information rather than a confession.
Look at ordinary dives that went fine, because that is where the adaptations live.
When someone describes something that works better than the written procedure, take it upwards instead of burying it.
When something does go wrong, hold off on the compliance question long enough to understand what the conditions were.
There is a personal version too. Next time you read about a fatality and find the moment where it all went wrong, ask what that diver was trying to achieve, what the day looked like from their perspective, and whether you have ever done something close to it and got away with it. Most of us have, and most recognise that there wasn't much of a gap between good and lucky.
The bogeyman is not the rules. It is the belief that following them is what keeps us alive, and that the people it did not keep alive must have failed to follow them. It is a comfortable belief, it scores well on a questionnaire, and it is why so little changes.
Which adaptations does your operation depend on that nobody has ever written down?
References
[^1]: Boskeljon-Horst, L. (2023). The Bogeyman Unveiled: Safety and Effectiveness within the Royal Netherlands Air Force. Doctoral dissertation, Delft University of Technology. doi:10.4233/uuid:315bdb50-a76b-4ce6-aa2b-fab05aa679b3. The compliance and bogeyman material is Chapter 4, published as Boskeljon-Horst, L., de Boer, R.J., Steinmetz, V. & Dekker, S.W.A. (2023). Aircrews, rules and the bogeyman: mapping the benefits and fears of noncompliance. Safety, 9(1), 15. doi:10.3390/safety9010015 [^2]: Boskeljon-Horst, L., Sillem, S. & Dekker, S.W.A. (2022). 'Ladder'-based safety culture assessments inversely predict safety outcomes. Journal of Contingencies and Crisis Management, 30(1), 1-20. doi:10.1111/1468-5973.12445. The study builds on Antonsen, S. (2009). Safety culture assessment: a mission impossible? Journal of Contingencies and Crisis Management, 17(4), 242-254, which found the same inverse relationship in oil and gas. [^3]: Boskeljon-Horst, L., de Boer, R.J., Sillem, S. & Dekker, S.W.A. (2022). Goal conflicts, classical management and constructivism: how operators get things done. Safety, 8(2), 37. doi:10.3390/safety8020037 [^4]: Jahn, J.L.S. (2019). Genealogy of an error: the multiple, contingent authoring of resilience in wildland firefighting. Human Relations, 72(11), 1728-1755. Discussed in Boskeljon-Horst (2023) as the source of the Forest Service doctrine change.
