Why ‘everyone is responsible for their own risk-based decisions’ isn’t the right approach to take

[The Chairman]

Ultimately, you are responsible for yourself in this life.

Very well put.

How is a new student supposed to do these things?

Common sense is not very common. I have noticed that the people who get hurt in one sport seem to get hurt in multiple sports. They also seem to be the ones duped by scams and confidence schemes. They never seem to catch a break. In fact, they have abdicated taking responsibility for their lives for so long that they are really bothered when they aren't coddled and their hands held. If you don't possess a healthy dose of skepticism then people are going to get you to do stupid things your whole life. Life is tough. You can either be smart and safe or accept the lumps that come from blindly following others.

Human behaviour is a consequence of the system we operate in and we need to create a system whereby risk is more obvious than it currently is in diving.

This is blame shifting and I find it as odious as it is insidious. I don't blame society for who I am: I blame me. I don't buy into the litigious nature of our society that wants to blame the other guy. Unless I am t-boned, the three people at fault for any accident I am in is me, myself and I. The buck stops with me.

The solution is to be more open about the near-misses, incidents and accidents which happen.

This, I fully agree with. The Mod Squad has worked hard to make ScubaBoard's Accidents & Incidents as well as Near Misses a positive learning zone. The same with the "Green Zones" that are comprised with New Divers and Basic Scuba. The "you're gonna die" mentality is just as anathema as the "it's just not my fault" mentality. It's great to be gentle and patient with newbies, but you'll notice a less gentle approach in the advanced and tech sections. If you encounter an overly harsh miscreant or troll, don't fight it out yourself. REPORT IT! That way the mods have something to do and they will let you know what, if anything, was done in regards to your report.

It's cathartic to share what you've been through and even tell us what you learned from it. However, be prepared for other users to help you put things in perspective. The lessons you learned may not be the only lessons you should have learned and frankly, you may have missed the point entirely. Put on your big boy/big girl undies and open your mind to learning something you weren't expecting. Don't justify your mistakes: learn from them. You're going to miss the best points if you're wasting your efforts being defensive. Humility is an essential part of learning.

 

[GLOC]

This is blame shifting and I find it as odious as it is insidious. I don't blame society for who I am: I blame me. I don't buy into the litigious nature of our society that wants to blame the other guy. Unless I am t-boned, the three people at fault for any accident I am in is me, myself and I. The buck stops with me.

Unfortunately, modern safety research which looks at high-risk industries (nuclear, aviation, oil & gas, healthcare...) counters your view. The 'choices' people make are not as simple as you make them out to be. Indeed, the whole premise of human factors and ergonomics based around the fact that our behaviour is part of the system in which we operate.

The training classes I provide put people into stressful and uncertain situations operating a spacecraft which they have never encountered before. They have tasks to complete and goals to achieve. They need to share information to achieve a positive output. Their task loading is high which means they are unable to see everything that is going on. More than 80% of those who undertake the first of four missions as part of the class fail because they do not see what is relevant and where their attention should be focused. By the end of the 2nd day and four missions, they understand that to succeed they need to share information, prioritise tasks and goals within the mission. As part of the learning, of the six people in class two are always observing which means they can see what it is like to be on the outside looking in while the other four operate the spacecraft. They have the capacity the individuals in the game don't have. Their observations go into the reflective debriefs so that all can learn. What is abundantly clear is that the situations, previous experiences and expectations all cloud/inform their judgement process which often leads to the wrong outcome. This isn't about blame for making 'poor' decisions, it is about learning how human decision-making really happens. And to make it more applicable to diving, they then have to identify a key lesson from the mission to their diving/instruction/workplace. I have used these simulations with many of those at the top of the industry as well as surgeons, anaesthetists and business executives. They all behave broadly the same. The online class has a number of tasks and in the main people 'fail' in the same way there too.

Something to consider from the research in high-risk industries. Given informed people with competency in technical skills, if there are continual failures of the same type at the 'sharp end' (i.e. the workers), then it is not a 'sharp end' problem. (See Safety at the Sharp End: A Guide to Non-Technical Skills)

Finally, the following written by Professor James Reason, sets out 12 systemic human factors centric principles of error management in his book Managing Maintenance Error: A Practical Guide which covers the point about systems and influence on human performance.

• Human error is both universal & inevitable: Human error is not a moral issue. Human fallibility can be moderated but it can never be eliminated.
• Errors are not intrinsically bad: Success and failure spring from the same psychological roots. Without them, we could neither learn nor acquire the skills that are essential to safe and efficient work.
• You cannot change the human condition, but you can change the conditions in which humans work: Situations vary enormously in their capacity for provoking unwanted actions. Identifying these error traps and recognising their characteristics are essential preliminaries to effective error management.
• The best people can make the worst mistakes: No one is immune. The best people often occupy the most responsible positions so that their errors can have the greatest impact…
• People cannot easily avoid those actions they did not intend to commit: Blaming people for their errors is emotionally satisfying but remedially useless. We should not, however, confuse blame with accountability. Everyone ought to be accountable for his or her errors [and] acknowledge the errors and strive to be mindful to avoid recurrence.
• Errors are consequences not causes: …errors have a history. Discovering an error is the beginning of a search for causes, not the end. Only by understanding the circumstances…can we hope to limit the chances of their recurrence.
• Many errors fall into recurrent patterns: Targeting those recurrent error types is the most effective way of deploying limited Error Management resources.
• Safety significant errors can occur at all levels of the system: Making errors is not the monopoly of those who get their hands dirty. …the higher up an organisation, an individual is, the more dangerous are his or her errors. Error management techniques need to be applied across the whole system.
• Error management is about managing the manageable: Situations and even systems are manageable if we are mindful. Human nature – in the broadest sense – is not. Most of the enduring solutions…involve technical, procedural and organisational measures rather than purely psychological ones.
• Error management is about making good people excellent: Excellent performers routinely prepare themselves for potentially challenging activities by mentally rehearsing their responses to a variety of imagined situations. Improving the skills of error detection is at least as important as making people aware of how errors arise in the first place.
• There is no one best way: Different types of human factors problem occur at different levels of the organisation and require different management techniques. Different organisational cultures require different ‘mixing and matching’….of techniques. People are more likely to buy-in to homegrown measures…
• Effective error management aims as continuous reform, not local fixes: There is always a strong temptation to focus upon the last few errors …but trying to prevent individual errors is like swatting mosquitos…the only way to solve the mosquito problem is to drain the swamps in which they breed. Reform of the system as a whole must be a continuous process whose aim is to contain whole groups of errors rather than single blunders.

 

[Colliam7]

Gareth very good post - interesting, and a useful basis for discussion. I think it captures the essence of quite a few situations that divers (perhaps, too many, unfortunately) find themselves in. I think it also applies to other life situations and endeavors. I can readily relate to what you did, and readily confess that I have probably made some equally poor (in hindsight) and uninformed decisions myself.

I agree with several of your statements:

To blame an individual for apparently daft decisions without understanding the context means that we will continue to have the same mistakes happening in diving. . . . The majority of violations in diving do not happen because divers are stupid or reckless, they happen because the divers are unable to examine the uncertainties involved and truly look at the possible negative outcomes . . .

Now, where I am a little confused: You conclude with a 'So what?' section. And, you start by saying what the blog isn't about:

This isn't about having a rule for each situation and getting people to follow them, because we know that won't work.

Fair enough. But, then, what IS it about? The title creates the same question:

Why ‘everyone is responsible for their own risk-based decisions’ isn’t the right approach to take to improve diving safety.

If this isn't the right approach, then what is?

As I stated, I agree with many of your statements in the blog. It is very difficult to fully understand the essence of a risk that you have not experienced before. In my own field of endeavor, I have been somewhat cynical about the value of having patients and research subjects sign an Informed Consent document, regarding a planned procedure or participation in a clinical trial, where 'death' is a possible risk - none of us have been dead before (putting aside the beliefs of certain religions for the sake of this discussion), so how can we truly understand what 'death' as a risk really means.

I also think it is too easy to sit back and draw conclusions about the behavior of others, to the point of assigning 'blame'.

And, if your point is that, in saying everyone is responsible for their own actions, we make it easy to dismiss a safety hazard on the basis of saying someone else was entirely responsible for an accident, therefore the safety hazard does not exist for me, then I am in agreement with you.

BUT, while I have a problem with 'blame-storming', and I think it is delusional to dismiss an accident as the result of another diver's stupidity, re-assuring myself that it won't happen to me because I am not an idiot, I also feel the need for honesty in assignment of responsibility for events. You allude to your own experience in aviation. And, what is the most commonly cited proximal cause of aviation accidents and incidents - 'Pilot Error'. That doesn't mean a pilot was 'stupid or reckless' (any more than divers are 'stupid or reckless'). But, they made bad decisions. And, we identity, and analyze, those situations in order to learn from them. 'That person made a bad decision (or series of decisions). What can I learn from that situation that may help me avoid making the same bad decision in the future. The alternative to assigning responsibility to the diver involved (or the pilot involved) might be 'S**t happens', which really doesn't contribute to a level of understanding that advances safety. Or, instead of assigning responsibility to the diver, we attribute the accident to some other factor. For example: over the past several years, that have been a series of diver deaths in a particular FL cave system. The posthumous criticism of the divers involved, for the behavior that led to their deaths, has been 'animated' at time. Perhaps, some of that criticism could be labelled as inappropriate 'blame-storming', and perhaps some of it has undermined attempts at objective analysis, discussion and learning. If concern about such blame-storming is at the heart of your blog, I agree with you. But, one of the results of these deaths has been a call to close access to the particular cave system, to all divers - which amounts to holding the cave system, and NOT the involved divers (and their flawed decision-making), responsible for the deaths. I do not believe that is appropriate, nor does it facilitate learning.

So, yes, I fully agree that sitting back and saying, 'That diver was a complete idiot - and I would never do something that stupid!' is not useful, and probably not appropriate in most cases, and dismissing the actions of others as idiocy may prevent us from learning. But, saying that 'we are all responsible for our actions, and therefore we must be actively, and continually, learning from our own experience and the experiences off others, so that we avoid making similar mistakes' would seem, to me at least, to be a necessary step toward reducing future failures.

 

[Eric Sedletzky]

How is a new student supposed to do these things? They have no knowledge to decide that the instructor is incompetent. On the other hand the instructor will probably have the branding of a large multinational company behind them. And there is the power relationship.

Read the manual first cover to cover like I did, It’s all in there. If they skip over stuff you’ll know. If they are lousy instructors and can’t seem to convey the information well that should be obvious too.

 

[The Chairman]

The 'choices' people make are not as simple as you make them out to be. I

Why are people so intent on misrepresenting what I posted? I never suggested choices were simple. We disagree on who is better suited to preventing an accident. You seem to be advocating fo an OSSHA style approach, while I feel a more personal approach is best.

@Colliam7 I actually believe that many errors are caused by depth induced stupidity. Some of you have read that I ascribe narcosis to achieving the mental alacrity of a cow. Putting on gear reduces your IQ by 15 points or so. Splashing robs another chunk and each atmosphere of pressure keeps detracting points. Before you know it, you’re as smart as a cow. Bovine index=1. Is it hopeless? Of course not. Common sense coupled with both training and research can keep anyone from having needless accidents. You’ve got to develop your inner spidey sense as well as take personal responsibility for your decisions. People seem to spend more time researching the next restaurant they’ll eat at than how to pick the right instructor. But it’s all the system’s fault. I disagree.

 

[boulderjohn]

This is blame shifting and I find it as odious as it is insidious. I don't blame society for who I am: I blame me. I don't buy into the litigious nature of our society that wants to blame the other guy. Unless I am t-boned, the three people at fault for any accident I am in is me, myself and I. The buck stops with me.

A number of years ago, the very large school district for which I worked became the first large school district to become ISO certified (it was then ISO 9000). I was put in charge of the internal auditing process, and I was the chief trainer in having departments analyze and improve their procedures. Their thinking is the opposite of "blame the person who made the error," and that difference is very important. When errors are made in the ISO system, you look to the operating procedures and the training on those procedures to see if you can spot a reason.

If you routinely blame the individuals making the errors, you can miss crucial problems in the procedures and training that can cause those same errors to be repeated again and again and again. The most famous example occurred in aviation, where a long series of pilot errors finally led to an analysis of the cockpit and a realization that the errors were primarily a result of the way the instruments were set up. Rearranging the instruments eliminated the errors. If they had just continued to blame the pilots, the errors would have continued.

 

[The Chairman]

@boulderjohn so your school system is now error free? Why not? Hopefully, you no longer count any answers as wrong, since that’s really the teacher’s fault, not the student’s. Oh wait, its not the teacher’s fault, it’s the school’s fault. Higher even? Where do we stop with the blame shifting? Ultimately, the student gets a good grade or a poor one. They either succeed and move on to higher education or they flip burgers for a living.

I can’t blame my high school for how much I don’t know. More importantly, I’m not going to. I’m not sure when personal responsibility fell out of vogue, but that’s a huge problem today. I don’t believe that when you make an error, you should blame anyone else but you. It’s not for me.

 

[The Chairman]

To clarify. I’m not above changing procedures. My Scuba class is unique Because I saw a better way. But no matter how well I teach my students, they and they alone are responsible for their safety. It’s up to them to assess conditions, buddies, gear and even crew. If you’re too lazy or busy, then you’re going to suffer or perhaps die. Like the guy who ignored the semi running the stop light. He might have had the right of way, but he’s still dead.

 

[GLOC]

@Colliam7 - the premise of the article (and my beliefs) are that simply attributing 'personal responsibility for poor decisions' will do nothing to improve diving safety without looking at the wider systemic issues. Part of that is the language used. Pete's comment of 'depth induced stupidity' doesn't help discussions but having safe spaces to discuss adverse events like the sub-fora here do. However, there is a definite need to get the knowledge from within fora like this and the Scuba Accidents FB group into something which can be used for both research as well as learning i.e. instructors use the content as learning examples rather than "We do this techique because we are told to do it"

I have seen the comments about Eagle's Nest and I don't know the solution. You are right it isn't the cave's fault that the fatalities happened. I would argue that there are always outliers in any system and you cannot create controls/mitigations for every person/situation. There are a number of goals in conflict: personal freedom to do what I like (selfishness?), failures at an individual level might (will) have much wider consequences and I have the right to sue anyone for something which I don't agree with. When you have goal conflicts, there are always trade-offs, that is another system trait.

@The Chairman, interesting comment that I misrepresent you with and yet you think I am looking for an OSHA view of the world Far from it, but the agencies at large do very little to ensure that what is actually taught is what should be taught and that students learn what they are supposed to. Just because a student doesn't file a QC form (I didn't know such systems were in place when I did my OW and AOW) it doesn't mean the instructor was doing what they were supposed to. I totally agree that people will spend more time picking something minor compared to life-support training and equipment but I would argue that is because the whole training system has been devalued with the race to the bottom in terms of price, 'pick your instructor not agency' and personal recommendations. The same applies to equipment. If you buy a piece of **** and it cost you several hundred dollars or thousands in the case of a CCR, are you going to openly tell everyone you bought some **** if it was all you could afford? Social pressure exists across many levels and so making a stand is sometimes very difficult.

@boulderjohn highlighted why looking at things in a systemic manner is important. For the others, the story he refers to relates to pilots raising the landing gear instead of the flaps and collapsing the aircraft on the runway, blocking the runway and normally causing major damage to the aircraft. They tried numerous training solutions, including disciplinary action, to change the behaviour but it didn't work. The levels were next to each other and were identical to touch. The solution was to put a small wheel on the landing gear level and moved spatially to a different location on the combing so that it wasn't automatic to raise the gear instead of the flaps. However, that improvement process requires a level of detail often missing from dive accident/incident reports. Often because no-one has asked them 'how did it make sense' and instead the social commentary is about 'you should know/be responsible for your own actions'.

 

[MaxBottomtime]

Read the manual first cover to cover like I did, It’s all in there. If they skip over A few stuff you’ll know. If they are lousy instructors and can’t seem to convey the information well that should be obvious too.

Exactly!
A few years ago there was a poster here who said that he didn't feel safe enough after getting his OW, AOW and Nitrox certs to dive without a DM. If you complete an OW course and don't feel safe enough to dive within the conditions you were trained to do then you either didn't pay attention in class or your instructor failed to teach you properly. If others in the class were able to dive safely then the problem is with the student. I would take a refresher course or go back and read the manual again until I fully understood it. It should never be up to someone else to hold your hand if you fail to learn.