Kategorie: News
A look at the system, not just the people
The accident in the Maldives from a ‘human factors’ perspective, for divers of all levels of training.
Article by Gareth Lock, first published in DAN Alert Diver
When five people lose their lives in a diving accident and a sixth dies during a rescue attempt, the diving community reacts in a way that may seem understandable at first glance: we look for the wrong decision, the person who made the mistake, and the rule that was broken. We are quick to pass judgement and close the investigation.
The following thoughts are an invitation to slow down this process, to use the methodical, logical part of our brain and to leave the emotional reaction behind. It is worth doing so: the questions we ask after an accident determine whether changes are made and whether attention is focused on the right aspects. Identifying learning objectives is not enough. Real learning means change.
This article is not an analysis of the incidents in the cave; investigations into them are still ongoing. Four families have waited a long time for clarity, and much of the online discussion in the days following the accident was speculative – as expected, but not very helpful. I have no privileged access to the facts, and the same applies to the other participants in the online discussion.
What I offer is an approach that begins well before the events take place and continues long afterwards. In fact, one of the participants in the rescue operation five years ago took a course with me and said afterwards: “The week was intense and demanding, but my thoughts often return to what I learnt. The course helped me to view such situations from a different perspective, and for that I am very grateful.”
The first narrative is always much the same
After almost every fatal accident, we hear the same story – even before the exact details of the incident emerge:
“They shouldn’t have dived there.”
“They were just recreational divers.”
“Someone should have known better.”
This story is very convenient because it ends with a reassuring thought: I wouldn’t have done that, so it couldn’t have happened to me.
The catch is that this narrative brings about no real change. Every aspect of the incident is attributed to the victim, and the rest of us can breathe a sigh of relief. This effect occurs so frequently that psychologists have a term for it. When things go wrong for others, we explain it away by referring to their character: careless, arrogant, inadequately trained. When things go wrong for us, we explain it in terms of the situation: we were busy or distracted, or we were just unlucky. We apply a strict standard to others, and a much less strict one to ourselves. The diving community does this with painful regularity after every serious incident.
The pattern was normal. The scale was not
The individual behaviours and conditions that lead to such accidents are not all that uncommon. Divers exceed depth limits, and single-tank divers swim through short tunnel passages in tropical reefs because it doesn’t take long, the visibility is good, and it’s always gone well so far.
Research divers venture into environments for which their training has not prepared them, because that is where they find the coveted data and the window of opportunity is short. Such breaches occur every week somewhere in the world. In the vast majority of cases, they cause no stir whatsoever, because in the end everyone is back on the boat safe and sound.
What set this case apart from others was not the structure of the behaviour, but the scale of the consequences. The reaction on (social) media and from individuals focused on the consequences, not the pattern. Yet it is the pattern that created the conditions in the first place. Recognising this distinction is important because the same pattern is at work this week too – on a different boat, in a different location, and during dives that are still being planned.
Why “rule-breaking” is rarely the whole story
When we talk about a rule-breaking incident, we usually think of a careless individual who doesn’t take the guidelines too seriously. Most rule-breaking incidents, however, are of a completely different nature: they are a well-trodden path that the entire system tacitly accepts because the written rules do not do justice to the demands of reality. The 30-metre depth limit is laid down in the rules, but the reality is quite different. Everyone involved knows this.
Therefore, rules are less about controlling behaviour and more about deciding who has to justify their actions if the worst comes to the worst.
Stick to the standards, have a bad day: the system dictates the explanation. Standards breached – standards that nobody in the local scene adheres to anyway – had the same bad day, and suddenly a common practice becomes a rule violation by a single person. The violation is collective, the responsibility is personalised, and it is solely the severity of the consequences that makes the difference. This also applies at an organisational level. If all associations and diving centres are doing something, it must surely be the right thing to do.
Peer pressure and the silence that looks like agreement
It’s worth delving a little deeper into one thread because of its broad applicability: when a group is planning something, the quietest members usually interpret the others’ silence as confidence and agreement. Privately, everyone has their doubts, but assumes they’re alone in having them. Speaking up would call into question the team’s self-image as a competent unit. From the outside, this looks like consensus. In reality, it may be that a plan is agreed upon with which nobody is really happy.
The diver who speaks up immediately pays the social price – before anything could happen. Those who remain silent get off scot-free, at least as long as everything goes well. This imbalance is structural. For this reason, “just say something” is a piece of advice that is harder to follow than it seems.
Building a team in which quiet doubts are voiced is one of the most useful areas for an organiser, diving instructor or buddy team to work on. This conviction forms the basis of the concept of psychological safety.
What sort of accountability do people want?
None of this means that nobody bears responsibility. However, whilst finding someone to blame is quick and can be satisfying, it rarely helps to prevent the next accident. Incidents arise from circumstances, not from the decisions of ‘idiots’ or bad people. Identifying these conditions is a slow, uncomfortable process, yet this process is the only approach that realistically works. We therefore need a change of perspective – before we look for someone to blame, we should ask ourselves three questions:
What led the people involved to believe that the decision made sense?
What circumstances made it more likely?
Which of these circumstances still exist?
The insight I hope you’ll take away
When planning your next dive, look at the depth, the gas, the environment, the equipment, the group, and the schedule. Which of these aspects meet the formal requirements, and which fall within the well-trodden path that the community tacitly tolerates?
If the dive had ended with negative consequences: which of these aspects would appear to outsiders as a blatant breach of the rules? And if everything goes well – which is the case in the vast majority of instances – would anyone have noticed anything?
These considerations are a measure of how much we (and you personally) have actually learnt from this tragic incident.
About the Author
Gareth Lock, MSc, is the founder of ‘The Human Diver’ and ‘Human in the System’, two organisations based on a single idea: that most adverse events in diving and other high-risk activities are due to system failures rather than human error. A former Royal Air Force officer with 25 years’ service as a flight crew member and systems engineer, he holds an MSc in Human Factors and Systems Safety from Lund University in Sweden. He is certified by GUE as Tech 2 and CCR 1 and has completed around 800 dives. Due to health issues, he has not dived for several years.
Original article published in DAN Alert Diver