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Why does a "they should", "they could" or "I would" approach not improve safety in diving?

When something has gone wrong and an accident has occurred, we are very quick to say how the incident could have been prevented. We use phrases like “if only they had done A…” or “they should have done B…” or “they could have done C…” or “I would have done D…”. We do this because
Published: April 28, 2020 - 09:00
Updated: July 22, 2023 - 19:39
Why does a “they should”, “they could” or “I would” approach not improve safety in diving?

When something has gone wrong and an accident has occurred, we are very quick to say how the incident could have been prevented. We use phrases like “if only they had 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 find a solution to prevent the same event from happening again in the future.

It is a natural reaction. We try to bring order to disorder. Thinking in this way is known as counterfactual justification (i.e. imagining what might have been – note). In its most basic form, we believe that if people had taken different actions in a given situation, the outcome would have been different. Unfortunately, by proceeding in this way, we apply variables that do not currently exist to a story that has already happened in order to tell a different one that has a happy ending.

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Here are some examples of diving-related scenarios:

  • Had the rebreather diver performed the series of tests correctly, according to his checklist, he would not have entered the water with the oxygen turned off, thus avoiding hypoxia and subsequent death.
  • If the diver had noticed before diving that the valve on his single cylinder had been turned off before entering the water, he would have had something to breathe and a way to fill his jacket. This would have prevented his drowning.

Putting order into disorder

We like alternative reasoning because it allows us to bring order to disorder and we believe that by doing so we will not make the same mistakes again. We apply hindsight believing that it will give us the ability to prevent situations if we encounter the same situation. We assume that we will not make the same mistakes because we assume that we know what we should do and we will perform the right actions to prevent negative consequences. We believe that we will prevent an undesirable event because we pay more attention and recognise the signs and clues that something is wrong.

Counterfactual thinking can and does keep us calm and safe because we think we know the solution to a difficult situation, but there is a problem here. Counterfactual reasoning does not increase our chances of the same event occurring in the future because it does not relate to the real world. It does not take into account the conditions that led to the error, mistake or rule violation. More importantly, our solution does not focus on why these “so obvious” factors were missed by the diver in real life, in a real situation. Essentially, then, the alternative inference (counterfactual) that we use relates to a story that did not happen.

Understanding the rationality of the moment

Let’s consider the difference between they didn’t do their checklist tests correctly and therefore the O2 remained screwed up and understanding the momentary rationality of the situation, why the divers didn’t exactly do all the tests on their checklist.

  • Were checklists usually used during the dive?
  • Has the use of the checklist and its flaws/criticality been discussed and covered in training?
  • Was the divers’ attention distracted while performing the checklist tests?
  • Did the divers feel the time pressure of entering the water?

Knowing what will happen is one thing, but often the events themselves have little to do with the contributing or causal factors, conditions or circumstances in the past that led to the events that occurred. Consequently, alternative reasoning does not lead to constructive solutions because it ignores questions about the causes and conditions that led to mistakes being made or contributing factors occurring. We have already established what needs to be done differently (from those involved in the event), so why look elsewhere for solutions? Counterfactual inference replaces inference based on the question “what were the circumstances that led to diver X doing Y?” with inference based on “diver X should have done Z instead of Y”. Thinking “they were stupid because it was obvious it was going to end this way” is another biased and falsified inference. If what happened was so obvious then different actions would have been taken right!

Summary

Counterfactual reasoning is only useful if we can, like Doctor Who, go back in time to prevent the events that have just occurred. In any other situation, alternative reasoning helps us feel better, but does not improve diving safety or our level of diving experience. Ironically, this action has the exact opposite effect and actively prevents us from improving and growing. This is because we are not looking for signs, clues and patterns that led to the incident that we can detect and respond to in the future.

Takeaway lesson: Instead of asking “why didn’t they do Y instead of X?”, let’s ask the question “how did it come about that doing X made sense to them at the time?”. We will learn much more about how to improve our future dives. Let’s ask questions about what happened instead of focusing on what didn’t happen.

P.S. By thinking that people are stupid because it was obvious that it would end this way, we are committing the error of bias. If it was obvious it was going to end this way (dead, injured, with DCS, etc.), wouldn’t the divers have done something to prevent it?


From the author:

When I started my adventure with technical diving more than 15 years ago, my instructor said “position, trim, buoyancy, configuration and ability to react to the situation is only 20%. The other 80% is the head”.

Over the years of training myself and other divers on numerous courses, acting as an instructor and being a psychologist by education, I cannot underestimate the impact of human factors on the quality and safety of diving. The vast majority of diving accidents in recent years, is a result of neglecting or neglecting the widely understood influence of the human factor on diving safety. This does not just apply to the accident situation itself, but more importantly to the culture, science, information, blame and capacity of the environment to share information in a factual way, without placing blame. In 2019, I read the book Under Pressure Diving Deeper With Human Factors. I developed a closer relationship with the author – Gareth Lock, owner of The Human Diver. I decided to promote the Just Culture philosophy and try to raise awareness of the importance of human factors in diving. I present an article that appeared on thehumandiver.com, and a book “Under Pressure” is also in preparation.

Andrzej Górnicki


Accident analysis, decision making, cognitive errors, Gareth Lock 24 August 2019 Original title: Why ‘They should have’, ‘…could have’ or ‘I would have…’ do not improve diving safety

the human diver Gareth Lock, He spent 25 years with the Royal Airforce as an aircraft instructor, navigator and engineer. Gareth founded The Human Diver In January 2016, in response to knowledge and training gaps related to human influence and assumptions Just Culture in the diving industry. He has taught over 350 courses and 20 presentations on human factors in diving. Published in March 2019, the book Under Pressure: Diving Deeper with Human Factors has sold nearly three thousand copies to date. Gareth runs The Human Diver website, and blog, as well as training and webinars. More information and original versions of articles can be found at The Human Diver.

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Andrzej Górnicki Andrzej GórnickiSport and technical diving instructor. Co-author of workshops on safe closed circuit diving. Trained as a psychologist and coach, associated with soft skills training. Graduate of postgraduate studies in Underwater Archaeology at the University of Warsaw. He has worked as an instructor, guide and dive base manager in Portugal, Croatia, Norway, Malta, Egypt, Sweden and Poland. Translates training materials for the largest organisations training and certifying divers. Author of articles related to diving. For years, he has been involved in disseminating the latest knowledge and trends in diving. Actively supports the Baltictech technical diving conference.

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About author

Andrzej
Andrzej Górnicki jest absolwentem psychologii. Trener i wykładowca, szkoleniowiec. Prowadzi szkolenia z zarządzania i kierowania zespołami oraz zasobami ludzkimi. Nurkuje od 2004 roku. Nurek rekreacyjny i techniczny z doświadczeniem przekraczającym dwa tysiące nurkowań. Od 2005 roku jest instruktorem Nurkowania. Ponad 100 licencji wystawionych w federacji SSI oraz ponad 100 w TDI i SDI.
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