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By Amanda White
“Be the change that you wish to see in the world.”― Mahatma Gandhi
Almost two years after the announcement of the Mission 2020 Pledge, nearly 200 dive industry organizations and businesses have pledged to do their part to reduce their company’s impact on aquatic environments.
For those of you who haven’t heard of it, Mission 2020 is a collection of pledges from organizations in the diving industry to change their business practices in order to help protect and preserve our oceans for the future. The primary focus of the pledge is to reduce or eliminate single-use plastic before World Oceans Day in 2020. Plastic is an issue that is at the forefront of a lot of consumers minds. Scientists from the nonprofit advocacy group “5 Gyres” found there are 5.25 trillion pieces of plastic debris in the ocean. Of that, 269,000 tons float on the surface, while almost four billion plastic microfibers per square kilometer litter the deep sea.
Mission 2020 was founded by UK-based dive garment company, Fourth Element in hopes of combating their contribution to the growing plastic problem. We caught up with 4E co-founder Paul Strike who is in charge of product development to see what the state of Mission 2020 is now.
How did Mission 2020 come about?
Jim [Standing] and I had a number of conversations at the 2017 DEMA tradeshow about doing something for the environment. A couple of months later we were discussing it [Mission 2020] again and came up with an idea: Wouldn’t it be amazing if we could actually encourage other people, other companies, to join us and do something that would make a difference? That’s how Mission 2020, as the industry knows it, was born. It’s not about Fourth Element, but about developing an industry initiative that will allow all of us to speak with one voice.
So it would have more power than just a single company behind it?
Yes, that kind of combined effect of having a number of companies: actually, in fact, a whole range of people and businesses and brands, dive centers, and organizations involved in the scuba diving industry, all coming together with one common cause– to do something positive for the ocean. There are nearly 200 entities that have made a pledge to effect change under that Mission 2020 heading. We are an industry that enjoys the ocean and makes a living off of it, so it’s in our best interest not to screw up our playground.
A strong and powerful message is being presented by the diving industry through Mission 2020. It could be the only and is certainly the first industry in the world to take some kind of combined, unified stance on this, one that is sending a strong message to consumers and other businesses.
Why did Fourth Element choose to focus on single-use plastics?
Well, think about how much plastic is involved in packaging a pair of scuba fins. And that’s a big, relatively heavy-duty plastic bag with a plastic carry handle that sometimes clips together. And I suppose it would be interesting to find out how many pairs of fins are sold in scuba diving. You know, that’s probably hundreds of thousands, isn’t it? And that’s just one product! It’s scary. That is just a huge amount of plastic. The magnitude of these plastic stats and of what’s going on globally is just… It’s mind-boggling. It’s so huge, the impact, it’s almost a bit like when people are talking about distant planets; it’s very difficult to get your head around it because it’s too big.
Thankfully, it’s something that so many people are talking about and obviously not just in the dive industry. You can’t seem to turn on the TV without there being something about plastic. Thankfully, there are lots and lots of companies changing things. But equally scarily, there are lots of companies that don’t seem to be making any changes.
What are you changing in order to reach your Mission 2020 goals?
Jim and I are both equally committed to trying to achieve these goals. The whole company is behind this mission. From the people designing and creating the clothing to those packing and dispatching it everyone in the company is behind this.
With hand on heart, we couldn’t promote an environmentally positive product, something that’s been made from recycled nylon, and then put it in a plastic bag. Obviously, on one hand, we were doing something that was in some way beneficial, while on the other hand, completely eradicating it. So that made us look more carefully at the packaging. And we have found various, or we have tried various means to package our Ocean Positive swimwear, ways that would be without the use of plastic right down to the Kimball tags and everything.
That’s your swimwear line made from recycled ghost finishing net right?
[Note: In 2009 the United Nations Food and Agriculture Organization (FAO) and the U.N. Environment Programme (UNEP) estimated that there were approximately 640,000 tons of abandoned fishing nets in the oceans, accounting for one-tenth of all marine litter.]
What is your timeframe?
Our deadline, our self-imposed deadline, is the World Oceans Day in 2020, by which time our ambition is to be single-use plastic-free from all of our packaging. And it will have taken us the better part of two years to get there. It’s not just a linear progression. We’ve made some leaps ahead, and we’ve changed quite a lot of things already. By the end of this year, we should be almost there, if not all the way there [single-use plastic free]. But I suspect we may have one or two little nuggety ones to solve in the early part of 2020.
And I think again, that’s the sort of message I’d like to put out there to everyone: as much as we all need to change our behavior to reduce the waste of single-use plastic, I think it’s unrealistic to expect individuals and/or companies to change everything overnight and some immediate changes may not be the perfect solution, but steps along the way to achieving a perfect solution and a necessary part of the process.
What are some of the difficulties 4E faced in achieving their plastic-free goals?
I mean there are so many variations, there are so many things to consider in this process. Everybody will have their own challenges, ones that are specific to their company structure and their supply chain. So it’s a multilayered, multi-complex challenge and a huge problem to resolve.
For us, it’s time-consuming, it’s expensive, it’s challenging. Unfortunately, the plastic bag is so good at what it does in terms of protecting a product. It’s clear; you can see the product through the bag. It’s cheap. It’s waterproof, just to name some of the beneficial characteristics of a plastic bag. And it’s incredibly good at doing what you actually want it to do.
The major downfall is that it stays around for hundreds and hundreds of years afterwards. And of course, we’ve seen the result of that in waterways around the world and horrible wildlife footage where you see whales that have been cut open with thousands of these bags inside of them. So trying to find a product, or safe products, that actually replicate the plastic bag is challenging.
What kind of replacements have you found so far?
We have investigated and used bags that are made from vegetable-based or plant-based material. And that works pretty well for a lot of products, for a lot of situations. But it has some limitations. And unfortunately, it’s not a kind of one-stop-shop of going, “oh great, we’ve got a replacement for the plastic bag! However, we do have a plastic bag type thing made from plant material which biodegrades, and it actually will break down in the water, and it can be eaten by a turtle and it doesn’t kill them. It can be digested by sea life. But unfortunately, it has its challenges with temperature, and it can get brittle, and sometimes it can crack. So it doesn’t achieve all of what we need it to achieve.
We’ve used paper bags, we are increasingly using paper bags for our T-shirts, which we then need to label very clearly. And so then, of course, we need to look at a paper-based sticker that is using a glue that is non-toxic. And that’s another little problem to solve.
Every step of the way there seems to be another step or two related to it which is something that needs to be resolved or something that needs to be overcome; whereas your plastic bag is so damn simple. And that is the fundamental problem.
So are there companies working on these problems?
There are companies that are taking the technology a bit further, there are better solutions every day. We are constantly looking at these because we haven’t found the ultimate solution, and they work for some products and not others. Sometimes there are size limitations to what’s possible and sometimes there are cost limitations to what is possible as well. So there are magnitudes of scale and economy like that, which can get quite scary from a cost point of view.
The other challenge is sifting through the actual science, the real science, behind the bags. Because a lot of the bags that are coming out, or at least some, will biodegrade. But they don’t necessarily biodegrade into biomaterial. They biodegrade into small particles of plastic, which is not what we want. The bag ceases to become a bag and it breaks down into little bits of plastic, but that really doesn’t solve the problem at all.
So, not every solution you’ve found solves the problem?
That one solves some element of the problem, that it’s less of a hazard to marine life. But the little bits of plastic will end up getting into the water table and will get into rivers and then end up being flushed out to the ocean. It’s the same way that the microfilaments that washed out of your fabric or your garments when you put them through a domestic washing machine, you’ve got the same fundamental problem there. These little microfilaments of plastic. So it’s pointless replacing a plastic bag with a bag that just breaks down into tiny bits of plastic. So you have got to be careful with regard to what types of solutions you find.
There are some real challenges, and they all take time. But we are getting there. And I think what is really encouraging, and we’re not saying that we’ve solved this problem, but the more little steps that we all take toward achieving the sort of endgame of eliminating single-use plastic, the more solutions that become apparent in the process.
Nice! How do you feel about industry participation in Mission 2020? Has it been well received by the dive industry?
I looked through the list again today to see who has signed up. And I feel really heartened by the fact that a significant number of brands and companies have jumped on board with it and made their commitment to do something different in order to benefit the ocean environment. Obviously, we make quite a few competitive products to some of the brands but it’s really been encouraging to see who has come on board. It’s fantastic that they are seeing the bigger picture.
We’ve got PADI. It was fantastic to get PADI on board. They exert so much influence in the world of diving generally, and they’ve encouraged a lot of their dive centers throughout the world to consider getting involved. GUE has already signed up and is doing the same. It’s fantastic to get major training agencies on board. That creates a great deal of influence amongst the diving industry, the diving market, and people who are involved in diving.
A lot of dive centers have also become involved. We’ve got dive centers that have signed up from Bali to the USA to the UK, virtually globally, and have made a commitment to doing things differently. I’m not exactly sure of the density in the areas that are the most significantly represented, but I was really quite encouraged by how widespread this has actually become.
What challenges do you face with improving the sustainability of your products?
The neoprene that we use in our wetsuits contains between 15 to 20% recycled material from car tires. So it’s an effective recycling process of car tires where 85 % of the car tire is recycled, and the black rubber material is integrated, or is used in the production of the neoprene and accounts for between 15 and 20% of the neoprene that is used in our suits. So again, it’s not the end game, but it’s a step in the right direction.
There is a huge amount of investment going into the reuse and recycle-ability of neoprene. And it may be that the endgame or the ambition of recycling neoprene wetsuits to make more neoprene wetsuits is probably a long, long way off because of the nature of the neoprene once it’s been laminated with the linings inside and out and stitched together etc. And then in order to recycle that material, that suit, there are many processes involved.
And that is one of the biggest impediments and a huge challenge to any recycling process, for when you have mixed materials and mixed construction, it becomes much more challenging to recycle that product. It’s almost impossible to separate different forms of plastic because they have different properties. So that is something, again, in this whole manufacturing process that we’re thinking more about. Like, what we can do to make the product easier to recycle at the end of its life? That’s another thing, going back to wetsuits, I think it’s much more realistic to think of neoprene wetsuits getting recycled for repurposing not as neoprene wetsuits anymore but something else that perhaps requires material similar to neoprene.
How about with your clothing?
Well, basically certain garments shed little microfibers more than others. And it often depends upon how tight-knit that fabric is. And you have a traditional fleece, and the fluffy surface is created by brushing loops, knotted loops of polyester, usually, and breaking them and splitting them and fluffing them up, shall we say. Now that obviously damages these loops and it breaks them and consequently, that is then more susceptible to little fragments breaking off in the washing process. So if you had a garment with the same composition but it’s tightly knitted and hasn’t been brushed, then it sheds fewer filaments.
So a rash guard and swimwear, by the nature of their construction, will shed many, many fewer filaments than a fleece that has been brushed significantly to create a fluffy, soft-feeling texture. Also, there is some evidence that at least suggests that the better the quality of the knit or the better the quality of the fabric, by and large, there is a reduction in the number of filaments that are lost because the knitting process is higher-quality, is a more secure knitting and in effect the garment doesn’t shed its yarn quite as easily. I’m afraid I’ve become a self-confessed fabric geek. I know more about fabric and knitting than I ever wished to know really.
What are the future plans after Mission 2020 has “ended”?
Obviously continued commitment to do what we can do, and hopefully, we will have eliminated single-use plastic from our packaging. I’m pretty confident that we will have achieved that. And part of the Mission 2020 statement is also about our continued quest for using recycled materials in our product range and looking for alternatives to harmful plastics. Some of our products use waterproofing technology which is less chemically toxic. The water runoff is cleaner.
We are actively working with fabric producing fabric knitters that are investing in more sustainable processes in their business. So, basically we will continue to choose a supply chain that minimizes environmental impact over ones that are carrying on as normal, shall we say. It’s about the plastic, in effect, but it’s also about the bigger picture. Therefore, we will continue to invest in and develop less impactful processes in the supply chain and production of our products.
Do you have hope for the future?
Obviously as we are all very aware, elimination of the single-use plastic is a global issue and I’m excited by going online and finding that there’s been a new breakthrough with this or somebody’s investigating this or come up with a technology that may not be the end game, but it’s improving and it’s making progress. We shouldn’t feel like we’ve failed because we haven’t gotten to the end game straightaway.
And what the great thing about all these things is that the more that companies actually look for these products, the more there are manufacturers and companies starting up, creating and selling products to replace plastics. When we started, there seemed to be only one viable option available. I’m sure it wasn’t one, but we found there were very few options in terms of getting something that was like a plastic bag, but not plastic. And now there seem to be more and more alternatives springing up every month.
What about consumers? There are an estimated 500 billion single-use plastic bags used each year by shoppers.
Ultimately, it comes down to consumers because they are one of the most powerful drivers, from a company’s perspective, as we all know. The movement depends on them. Once consumers become aware, take a stand, and actually change their behavior, companies will have to come around. If a company experiences a decline in the sale of a product because aware consumers see little to no effort toward reducing or ending single-use plastic, the company will have to make changes.
And I suppose this is almost a kind of plea or mandate to consumers to think about your choices. Of course, if it costs more to buy the environmental product. And some people may be lucky enough to be able to do that, but many people aren’t. However, we are finding that the price difference between an environmentally friendlier product, whether it’s the way it’s packaged or the way the materials are used, is getting narrower.
As for Mission 2020, it would be great to see the dive industry as a whole adopt this challenge.
Global Underwater Explorers has made a Mission 2020 pledge. At GUE, we pledge to launch an annual GUE Cleanup Event. We feel we can have the greatest impact by utilizing our network of divers in a worldwide cleanup of our waters. We hope to power our office with solar in the near future, will continue to recycle, and eliminate any single-use plastic from our products.
Amanda White is an editor for InDepth. Her main passion in life is protecting the environment. Whether that means working to minimize her own footprint or working on a broader scale to protect wildlife, the oceans, and other bodies of water. She received her GUE Recreational Level 1 certificate in November 2016 and is ecstatic to begin her scuba diving journey. Amanda was a volunteer for Project Baseline for over a year as the communications lead during Baseline Explorer missions. Now she manages communication between Project Baseline and the public and works as the content and marketing manager for GUE. Amanda holds a Bachelor’s degree in Journalism, with an emphasis in Strategic Communications from the University of Nevada, Reno.
The Role of Agency When Discussing Diving Incidents: An Adverse Event Occurs—An Instructor Makes a Mistake
Human Factors educator and coach Gareth Lock examines the role of our innate attribution biases and language, in forming our collective judgements when incidents occur—in this case, by considering a student diving injury that occurred during a class. Was the instructor to blame? Was anyone?
by Gareth Lock
Header Photo by Alexandra Graziano
What do you think when you read the following? Who is at fault? Where do you think the failures lie?
“The instructor failed to notice that the gas pressure in one of their four student’s cylinders was dropping faster than was expected, and consequently, missed that this particular student had run out of gas. The student then panicked and bolted for the surface which ended up with them having an arterial gas embolism.”
It would be normal for the majority of Western-cultured divers to believe that the fault would lie with the instructor, especially as I framed your thought processes with the subtitle, ‘An Instructor Makes a Mistake’.
The instructor would have had a clear level of responsibility to make sure that the event didn’t happen the way it did, and because the student ended up with an out-of-gas situation and an arterial gas embolism, that instructor needs to be held accountable for the mistakes that were made.
Financial compensation to the diver might be involved. As for the instructor, specific solutions for ways to prevent future mishaps would be standard. The instructor might be advised to be more aware, to monitor students more closely, and follow standards and/or training.
The problem with this approach is that it can miss significant contributory factors. Over thousands of years, we have developed a mindset that searches for the cause of an adverse event so that we can prevent the same thing from happening again. There are two parts behind this sentence that we are going to look at in this article—agency and attribution.
Agency and Attribution
The first is Agency—an agent is a person or thing that takes an active role or produces a specific effect. ‘The instructor failed to notice the faster-than-normal pressure drop.’ In this example, the instructor is the agent. While we can easily identify the action and agent, we cannot determine from this simple statement whether the instructor intentionally didn’t monitor the gas, whether they accidentally missed the increased consumption rate or leak, whether the student didn’t inform the instructor, or if there was another reason. A reader of this short case study would normally assume that the instructor had some choice in the matter, that they were a free agent with free will, and that a professional with training should know better. This assumption can heavily influence how an ‘investigation’ develops from a blame-worthy event to one where wider learning can happen.
Research has shown that the attribution of agency is subjective and is swayed by a number of different factors including culture, experience, and the language of the observer. Furthermore, the language used and how this frames the event has also been shown to directly influence the assignment of guilt, blame and/or punishment. This is especially the case if the only reports available are based around litigation and insurance claims, as these are purposely written to attribute blame.
Societally, and developmentally, we believe that the attribution of cause behind an action is important, especially if it is an adverse event because it allows us to identify who or what needs to change to prevent the same or similar events from occurring in the future. In the out-of-gas event above, it might be obvious to some that it is the instructor who needs to change or ‘be changed’!
The Fundamental Attribution Bias
While agency is relatively clear when we describe an event, where this attribution of agency is applied is very subjective. Attribution theory was developed in the 1950s by Fritz Heider in which he described behaviours that could be attributed to internal characteristics or disposition (personality, abilities, mood, attitude, motivations, efforts, beliefs…) or to the influences external to them which were situational in nature (culture, social norms, peer pressure, help from others, organisational pressures, rules, environmental conditions…). For example, a diving student might not perform as expected despite having been given the training detailed in the course materials. This could be because of performance anxiety, lack of confidence, not paying attention to the demonstrations… (internal or dispositional attribution), or it could be caused by an argument they had had at home that morning, mortgage worries, homework which is due, promotion or threat of being fired, or poorly serviced equipment… (external or situational attribution).
This subjectivity is so powerful and prevalent that there is a recognised cognitive bias called the fundamental attribution bias or error. This bias shows that there is a tendency to look for dispositional attribution when an adverse event involves someone else (they didn’t pay attention, they didn’t have the skills or experience), but the tendency to look for situational attribution when the adverse event involves us (high workload led me to be tired, the students were spread far apart, their gauge was in their BCD pocket). “When explaining someone’s behavior, we often underestimate the impact of the situation and overestimate the extent to which it reflects the individual’s traits and attitudes.” As a consequence, it is much easier to ascribe the failure to the individual rather than to look at the wider situation. This aligns with Lewin’s equation, B=f(P, E), which states that an individual’s behavior (B) is a function (f) of the person (P), including their history, personality and motivation, and their environment (E), which includes both their physical and social surroundings.
Research has shown that culture can strongly influence how agency is attributed. Those from Western cultures e.g. Anglo-American or Anglo-Saxon European, have a tendency to be more individualistic in nature, whereas those from Far Eastern cultures have a more collective view of the world which increases collaboration, interdependence and social conformity. The research also shows that “Compared to people in interdependent societies, people in independent societies are more likely to select a single proximal cause for an event.” Western cultures therefore have a tendency to erroneously attribute control and decision to the human actor closest to the event, even if this was not the case. This has huge implications when it comes to litigation and organisational/community learning.
Self-Serving and Defensive Attribution Bias
When it comes to an adverse event, those cultures that have high individualistic behaviours are more likely to find a way to identify someone other than ourselves as the cause i.e. “the dive center manager didn’t tell me the time had changed, and so I was late for the boat.” Conversely, when we have a successful outcome, we are more likely to look to our own performance and traits (dispositional attribution) rather than the context (situational attribution) i.e. “I had spent time practising the ascents, so my buoyancy was good for the final dive.” without noticing that their buddy was rock solid in the water and provided a very stable platform to reference against. This is known as self-serving self-attribution.
As the severity of the event increases, we mentally distance ourselves further from the traits or behaviours that would have led to this event. “I wouldn’t have done that because I would have spotted the situation developing beforehand. I am more aware than that diver.” This defensive attribution is also known as distancing through differencing.
This is a protection mechanism; if we can shift the blame to someone else because they have a different disposition (internal behaviours/traits), we can convince ourselves that what we are doing is safe, and we carry on with what we were doing in the same way we’ve always done. This might appear to be simplistic; however, much of what we do is relatively simple in theory, it is how it is weaved into our daily lives that makes things complicated or complex.
Language Matters – Invisible Meanings
The subtitle of the first section “An adverse event occurs. An instructor makes a mistake.” will have invoked a number of mental shortcuts or heuristics in the reader. We will likely make an assumption that the two events are linked and that the instructor’s mistake led to the adverse event. I purposely wrote it this way. That link could be made stronger by changing the full stop to a comma.
Language can have a large impact on how we perceive agency and causality. The problem is that how we construct our messaging is not normally consciously considered when we write or speak about events. As with many other aspects of culture, it is invisible to the actor unless there is some form of (guided) active reflection.
For example, research has shown that there is a difference between how Spanish and English-speaking participants considered the intentional or unintentional actions in a series of videos. In one example, the actor in the video would pop a balloon with a pin (intentional) or put a balloon in a box with a (unknown) pin in it and the balloon would pop (unintentional) as the balloon hit the pin.“The participant descriptions were coded as being either agentive or non-agentive. An agentive description would be something like, “He popped the balloon.” A non-agentive description could be, “The balloon popped.” The study concluded that English, Spanish, and bilingual speakers described intentional events agentively, but English speakers were more likely than the other groups to use agentive descriptions for unintentional events. Another study showed similar results between English and Japanese speakers.
Another powerful bias exists in the form of framing. This is where information is given to another party to influence their decisions and is either done consciously or not. For example, take two yoghurt pots, the first says “10% fat” and the other says “90% fat free”. The framing effect will more likely lead us to picking the second option, as it seems likely it is the healthier yoghurt. If we look at how this applies to diving incidents and agentive language “The diver ran out of gas near the end of the dive.” or “Their cylinder was empty near the end of the dive.” The first appears to put the diver at fault but we don’t know how or why this happened; whereas, the second statement is not personal and therefore allows a less confrontational conversation. Consequently, we must be careful with how we attribute agency as it limits our attention to the context immediately surrounding the person involved. If we want to learn, we have to expand our curiosity beyond the individual and look at the context.
Another example of how language matters and the shortcuts we use is the use of binary oppositions e.g., right/wrong, deep/shallow, recreational/technical, success/error, or deserved DCS/undeserved DCS. While binary modes might work for technical or mechanical systems (work/don’t work), they are not suited for systems involving people (socio-technical systems) due to the complicated and complex interactions that are present. “They didn’t use a checklist.” Is often seen as a final reason why something went wrong, as opposed to asking questions like “What sort of checklist should have been used?”, “When would the checklist normally be used?”, “What were others doing at the time”, “Which checklist? Manufacturer’s, agency’s, or their own?”
When it comes to these socio-technical systems, we can only determine success or error/failure AFTER the event. If the actors knew that what they were doing would end up as a failure due to an error, they would do something about that ‘error’ before it was too late.
Isn’t this just semantics?
All of this might appear to be semantics, and technically it is because semantics is the branch of linguistics and logic concerned with meaning. “Words create Worlds” (Heschel and Wittgenstein) for the better or worse. Think about how you frame an event or attribute agency because it WILL impact your own and others’ learning.
Look back at the original narrative in the second paragraph, which was purposely written in the manner it was, and consider where attribution has been placed, how it limits learning and what questions you can ask to improve your understanding of the event. We are cognitively efficient creatures, always looking for the shortcut to save energy. However, this efficiency comes at the expense of learning.
In this event, there were many other factors that we needed to consider, many of which would be focused on the limitations of our cognitive system. We CANNOT pay more attention; it has a limited capacity. What we can do is make it easier to prioritise and focus on the most important/and or relevant factors, and we do this by designing systems that take our limited capacity into mind.
Monitoring four students is going to be at the limits of what is safely possible, especially when other factors are taken into consideration, such as instructor experience, visibility, current, task loading, comfort levels, etc. These factors are readily apparent and their significance obvious after the event, but in real-time with all of the other conflicting goals present, not so. When designing systems and processes, try to apply the key human factors principle: make it easier to do the right thing, and harder to do the wrong thing.
As an example of how this language can manifest itself, have a look at any agency training materials which describe adverse events or incidents, and look to see how agency and attribution are applied, and how little the context is considered. e.g. the following example is from a leadership-level training manual: a supervisor left the dive site before accounting for all of the divers in the group and two were left behind and suffered from hypothermia. The reason given for the abandonment was that the supervisor was distracted. The material then goes on to say that despite the supervisor having normally conducted good accounting procedures, this would not help in a lawsuit as a court would look at the event that occurred not what they normally did. What is missing is understanding ‘how the supervisor came to be distracted’ and what the context was. This would provide a much greater learning opportunity than the normal ‘make sure you account for everyone otherwise you could be in a lawsuit.’ “We cannot change the human condition, but we can change the conditions in which humans work.”—Professor James Reason.
We have a tendency, especially in Western cultures, to want to find out ‘who did it’ and ascribe blame to an individual agent. More often than not, the agent is the person who was closest to the event in time and space. In effect, we play the game of ‘you were last to touch it, so it was your fault’ but this rarely prevents future events from occurring. In reality, divers, instructors, instructor trainers, and dive centre managers are all managing complex interactions between people, environment, equipment and cultural/societal pressures with sensemaking only being made after the event.
To be able to identify a single cause of an adverse event in diving is impossible because it doesn’t exist and yet this is what the language we use focuses on. We look for a root cause or a trigger event for an accident or incident. The research from Denoble et al, which described four stages (trigger event, disabling event, disabling injury and cause of death) of fatalities misses the context behind the trigger events and yet it is still used in incident analyses. Compare this to modern safety investigation programmes which have moved away from a root cause approach to a more systemic approach, like Accimap or Human Factors Analysis and Classification System (HFACS) that take into account systems thinking and human factors principles/models.
A response from Petar J Denoble’s response, Click Here
There are no formal investigation and analysis programmes or tools in the sports diving sector so any data that is produced is heavily biased by personal perspectives. However, that gap will be addressed before the end of 2021 when an investigation course will be launched to the public by The Human Diver.
This two-day programme will provide an introduction to a systems- and human factors-based approach to event learning and will be based on current best practices from high-risk industries and academia and then tailored and focused on non-fatal events in the diving industry. There will also be a number of research programmes being developed over the next year or so which look at incidents, their causality and how to report them. The methodology will be relevant to fatalities but these investigations are often undertaken by law enforcement officers or coroners.
For the diving community, there is a need to look at how adverse events happen, not by attributing agency to individuals, but to look wider, to the system and the context so that we can understand how it made sense for that human agent to do what they did at the time. Ivan Pupulidy covers this clearly in the US Forest Service Learning Review, “In order to change culture, you have to change the assumptions that drive the culture.”
After note: The article was heavily influenced by the work of Crista Vesel whose referenced paper examined agentive language and how it influenced how the US Forest Service moved from Serious Accident Investigation Guide to a Learning Review. The review allowed more genuine inquiry to occur and find out the real reasons why serious events, including fatalities, occurred. You can find Vesel’s paper here: “Agentive Language in Accident Investigation: Why Language Matters in Learning from Events.”
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7. Denoble, P.J; Caruso J.L.; de L Dear G.; Pieper C.F. and Vann R.D. Common Causes of Open Circuit Recreational Diving Fatalities. 2008
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Gareth Lock has been involved in high-risk work since 1989. He spent 25 years in the Royal Air Force in a variety of front-line operational, research and development, and systems engineering roles which have given him a unique perspective. In 2005, he started his dive training with GUE and is now an advanced trimix diver (Tech 2) and JJ-CCR Normoxic trimix diver. In 2016, he formed The Human Diver with the goal of bringing his operational, human factors, and systems thinking to diving safety. Since then, he has trained more than 350 people face-to-face around the globe, taught nearly 2,000 people via online programmes, sold more than 4,000 copies of his book Under Pressure: Diving Deeper with Human Factors, and produced “If Only…,” a documentary about a fatal dive told through the lens of Human Factors and a Just Culture. In September 2021, he will be opening the first ever Human Factors in Diving conference. His goal: to bring human factors practice and knowledge into the diving community to improve safety, performance, and enjoyment.
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