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By Guy Shockey
Header Image by Derk Remmers
At first glance, the title reads like a bit of an oxymoron. How can a standard operating procedure (SOP)—which implies a ‘one size fits all’ solution to problem solving—also be flexible? How can flexible also be firm?
One of the things that initially attracted me to Global Underwater Explorers (GUE) was the presence of SOPs. For anyone with a military background, SOPs were our bread and butter. You can create a good SOP while you have the time to think and plan. You can put them into practice, refine them over time, and keep them in place until new or better information comes along to change them.
For example, airline pilots have a binder full of SOPs for various contingencies. When something comes up, they turn to the correct page and find a list of actions to follow. Pilots understand that these SOPs represent the collective knowledge of many aviators and engineers that have come before them. Many of them have also been revised multiple times, codified, and then even revised after that. Some SOPs require commitment to memory because there may not be a lot of time, and pulling out a three-ring binder or flipping through your iPad to the correct page isn’t the appropriate action. In that case, then those same pilots practice these situations regularly in simulator training.
One of the primary values of an SOP is that it frees up a lot of situational awareness information processing. You are able to match up “mental models” to the current situation and, rather than processing your information in small bite-sized pieces, you are able to process “chunks” of information that match patterns of something that you know or are familiar with.
Let me create an analogy that may help make this clearer. If I were to give you a bowl of tomato sauce, some slices of pepperoni, some mushrooms, some cheese, and a piece of baked dough, you could eat them all one at a time and try to figure out what it was you were eating. Or, I can put all those ingredients on that same piece of dough, bake it, and you would instantly know that you were eating pizza. You don’t have to process all the ingredients one at a time. You already have an existing mental model that says “pizza.” We do this when we solve problems. We pattern-match and identify existing mental models all the time, and it’s actually the only way we can actually think as fast as we do. Many problems are actually solved with multiple mental models being applied together.
Having an SOP gives you the ability to solve problems more efficiently and effectively because you have a ready-made mental model or solution to a recognized problem. Think of every first aid course you have ever taken and the “ABCs” of first aid. SOPs are incredibly valuable in nearly every environment that includes potential risks.
If an SOP is shared, it also allows diverse groups to work together. It is no surprise that SOPs from various militaries of the world are often similar, even if they are written in different languages. From personal experience, NATO countries can coordinate and execute complex military operations because they share common SOPs that, if not identical, are very similar and don’t require much adjusting to mesh together. Common expectations and goals can be shared toward a common purpose.
When in time-sensitive environments, many of these SOPs and the corresponding mental models they help develop can be lifesaving. This doesn’t just apply to the military, but also to law enforcement, paramedics, firefighters, pilots, and any other profession that is often faced with time pressures in making critical decisions.
Do you share a common operational picture?
There is an interesting term often used in military circles called the “common operational picture” (COP). This is exactly what it sounds like, and is sometimes referred to as “a single source of truth.” Everyone involved in a decision-making cycle needs to be privy to the information that affects their decision. Sharing that information allows us to make informed decisions that often include SOPs. You could argue that we are creating a mental model that lets us apply another mental model!
Alright, so how exactly does all this apply to diving and GUE diving in particular? I’m pretty sure that many of you have already connected many of the dots.
In the GUE world, our divers create a COP at the beginning of the dive. We help reiterate this COP with our GUE EDGE pre-dive checklist, which is a great example of an SOP! We review the goals, team roles, our equipment, and the operational parameters of the dive, all in a standardized format that efficiently accommodates teammates from multiple different languages and cultures. I have performed GUE EDGEs in about 10 different languages and I only speak two! The fact that we were doing this in a standardized fashion meant I could follow along and knew what they were talking about.
As the dive plan complexity increases, so too does the COP become more complex. Some of our more ambitious exploration projects require even more time spent in planning than actual execution. But because there is a COP, coupled with SOPs (I know that’s a lot of acronyms), these projects usually go off without a hitch.
During the dive, there are multiple times that we have team-expected actions that are based on SOPs, and this contributes to and reinforces our COP. It is almost as if we are filling in a PDF form as we go along and confirming the various pieces of information that we need to complete the entire “form” or plan.
In the case of emergencies, we have ready-to-implement SOPs for just about any equipment malfunction from valve failures to losing your mask. We practice these SOPs so that, in real time, we can employ them in a timely fashion and resolve the problem. These SOPs are just like the ones I mentioned at the beginning of this article and were developed over time and refined with successive reviews and after-action analyses. Finally, they have been codified, and you can now find them in our GUE SOP manual! You will also notice that this manual is of a particular “version,” which tells you that the SOP is constantly being fine-tuned in a dynamic process.
How Can An SOP Be Flexible?
In reality, it isn’t the actual SOP that is flexible, but it is the degree of flexibility it provides to the dive plan itself that is of value. Let me give you an example from the technical diving world.
Imagine the team is diving on a wreck and experiences a delay on the bottom for whatever reason. It could be that it was done on purpose (discovery of pirate gold!) or maybe it was imposed upon the team as a result of any number of problems, like dealing with an equipment problem or an entanglement, for example. The dive is longer, the decompression obligation is now going to be longer, and there are some decisions to be made.
Having an SOP here can help provide a solution to the problem with no mess and no fuss. The divers dig into the bag of tricks they learned in GUE technical training, and because of their common operational picture and team-expected actions, they apply the SOP they practice regularly and modify their decompression schedule to suit the new bottom time. What could have been an exciting moment for many divers turns into just another discussion point for their debrief after the dive!
So, while SOPs are usually not flexible in and of themselves, they allow for a great deal of flexibility while diving by freeing up mental processing power and providing ready-made and practiced solutions to potential problems.
GUE SOPs presuppose the presence of personal diving skills at a high level, and assume that factors such as good buoyancy and trim are second nature. In fact, many of the SOPs state the first step in resolving a problem as “stabilize” or “stop” in all three dimensions. GUE divers see that, as the diving gets more complex, the SOPs also get more complex. For a new GUE Fundamentals diver, demonstrating some of the SOPs required to pass muster as a Tech 2 or CCR 2 diver look more akin to channeling “the force” than anything else. However, like most things, perfect practice produces perfect performance, and so it’s just a matter of putting in the repetitions.
For me, diving has never been the end but the means to the end. Anything I can do to make those means take up less mental and physical horsepower means that I can devote more of the same to the end goal. And at the end of the day, I am really all about that pirate gold!
Note that GUE members or divers taking a GUE course receive access to GUE’s 30-page manual, Standard Operating Procedures.
Guy Shockey is a GUE instructor and trainer who is actively involved in mentoring the next generation of GUE divers. He started diving in 1982 in a cold mountain lake in Alberta, Canada. Since then, he has logged somewhere close to 8,000 dives in most of the oceans of the world. He is a passionate technical diver with a particular interest in deeper ocean wreck diving. He is a former military officer and professional hunter with both bachelor’s and master’s degrees in political science. He is also an entrepreneur with several successful startup companies to his credit.
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.”
1. Lexico. Explore: agent. http://www.lexico.com/en/definition/ agent (accessed July 30, 2021).
2. Agentive Language in Accident Investigation: Why Language Matters in Learning from Events Crista Vesel ACS Chem. Health Saf. 2020, 27, 1, 34–39. 2020 3. Myers, D. Social Psychology, 11th ed.; McGraw-Hill: New York, 2013; pp 100−117
4. Fausey, C.; Long, B.; Inamon, A.; Boroditsky, L. Constructing agency: the role of language. Frontiers in Psychology 2010, 1, 1−11.
5. Dekker, S. Why We Need New Accident Models; Lund University School of Aviation: Sweden, 2005.
6. Fausey, C. M.; Boroditsky, L. In English and Spanish Speakers Remember Causal Agents Differently, Proceedings of 30th Annual Meeting of the Cognitive Science Society, Washington, DC, July, 2008. https://escholarship.org/uc/item/4425600t (accessed November 13, 2019).
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
8. Learning Review (LR) Guide (March 2017); U.S. Department of Agriculture Forest Service accessed 30 Jul 2021
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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