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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.
Andy Torbet: The Swiss Army Knife of the Diving Community
In this era of heightened stress, dive engineer and content producer, Carlos Lander thought it useful to speak to someone who manages prolonged stress in extreme situations. That man is Andy Torbet, a former British special forces officer, cave diver, freediver, rock climber, sky diver, BBC host and producer and DAN Europe Ambassador. Oh did I mention he’s Daniel Craig’s stunt double in the new 007 movie, “No Time to Die.” Here’s what Torbet advised.
by Carlos Lander. Photos courtesy of Andy Torbet
The COVID-19 pandemic has created new stressful situations that have raised our awareness of the impact of stress on our mental and physical health. I was, therefore, enthusiastic to talk with Andy Torbet, someone who has—in the past and present—successfully managed prolonged, extreme stress in survival situations.
In his former life, 45-year old Andy Torbet was a bomb disposal officer and maritime counter-terrorism agent for the British Army. When he made the leap to civilian life, he remained within the realm of extreme adventures, becoming one of the finest Briton underwater explorers; he’s a professional cave diver, skydiver, free diver, climber, TV presenter, and filmmaker. His most notable programs include BBC’s The One Show, Coast, Operation Iceberg, Operation Cloud Lab, Britain’s Ancient Capital, The People Remembered.
He co-produced the children’s BBC series Beyond Bionic, which was adapted into a computer game: “Beyond Bionic—Extreme Encounters.” Torbet’s first book, Extreme Adventures, was published in 2015, and he became a host on Fully Charged in April 2020. More recently, he can be seen in the new James Bond film, No Time to Die. He’s obviously a guy who excels in many fields, so he’s familiar with stress and has some ideas about how to cope with it.
Torbet’s prolific diving career memorably includes the Britannic expedition in 2016 for a BBC documentary. He was also involved in “The MV Shoal Fisher—The Mystery Shipwreck,” about a wrecked World War II merchant ship in the English Channel. Andy himself admits his solo exploration of The Cave of Skulls, Scotland’s deepest pot hole system, was “probably the most hardcore” of his adventures. That dive involved crawling through tight and flooded passages, getting stuck, and finally releasing his breath hold just enough to squeeze out of trouble. His book vividly details the harrowing dive and takes readers on a spine chilling adventure, as it did me.
When thinking about Torbet, a Swiss Army Knife comes to mind—an instrument designed to be useful in many situations. Another analogy might be Tony Stark without the Iron Man suit. Or, perhaps, a modern-day Sir David Attenborough. When presented with these options, he happily chose the knife comparison. Mr. Torbet has a compelling set of tools to call upon: He’s a loyal family man, has a sense of purpose, is resourceful and righteous, a teacher, and a risk management expert who can compartmentalize, communicate, and be playful. Oh, and he’s humble.
Torbet began his journey in the beautiful Scottish highlands. Born in 1976, he was an outdoor kid, climbing trees and playing in the lochs with his brother, who has joined him in many adventures over the years. At 20 having finished his university degree in zoology, Torbet joined the Army, inspired by his brother who had enlisted when he was 16. Torbet also admitted that joining the military was a way to see the world—it appealed to his desire for adventure—and to “make some decent money.” According to Torbet:
“Anyone can have a desire for exploration, but desire won’t get you there; action will. That doesn’t mean being reckless. It means taking the time to build discipline and to acquire the skills and knowledge you need to do whatever you do safely, also balancing the risk with sometimes needing to say, ‘Fuck it, here I come!”
The Torbet Method for Managing Stress
Mr. Torbet has three favorite sports: diving, skydiving, and “Esoteric Climbing” (where the bedrock is likely to be loose, fragile, and crumbling). Andy explained that, while climbing, he does not need to look down, because he knows how much distance he’s covered. “Even in this type of climbing, when I’m not or I don’t feel entirely in control, I don’t look down,” he said. “It won’t do any good.”
Why? Sometimes we can’t change an external situation, and that shouldn’t affect our emotions. What is important is how we react and how we reframe it. As Torbet put it:
“What we choose to do and how we choose to act is what counts, and this is all within our power to influence. In fact, sometimes when injuries are crippling us, time is against us, the weather is beating us back, and our kit is failing. Our attitude—the mindset we hold as we walk through the world—is the only thing we can control.”
Although Torbet has been in many military incursions, he prefers cave diving as an example of managing stress since, in his opinion, underwater caves are the most hazardous environments available to us. “[Underwater caves are] an alien world here on earth, and from a psychological point of view, very oppressive,” he explained. “It’s dark, isolated, cold, and claustrophobic. Therefore, we must deal with those realities long before we enter the cave.”
There are a few things that Torbet believes we should do to manage stress. First, evaluate the “what if” scenarios familiar to the diving community. Second, gain and maintain proficiency in the skills needed to manage those situations. Third, have the proper equipment and make sure it has been tested. And last, we must be mindful of what we are doing at all times. He also posits that, in an emergency, having fewer choices is better than having many; it reduces the time needed to choose a plan of action and allows us to more easily draw on our training and preparation. Not all situations can be foreseen. As Torbet explained,
“Do not lose yourself in emotions. Be present. I could be a mile from the cave exit; it does not matter. My concern is with the moment. I know that because I prepared myself, I have a proper plan for contingencies. Something random that I did not expect may occur, but I remain calm, focused on making my way out. I do not succumb to emotions, and I am focused because I prepared myself mentally and physically for this. You don’t save your life at that moment, you save your life in the days, months, and years before that.”
In this way cave diving is reduced to managing a sustainable level of pressure during prolonged periods of time, while maintaining concentration on techniques.
A Team of One?
Solo diving is a reality of exploring caves in the U.K. Paths are often so narrow that sometimes divers need to crawl, and more than one person will not fit. In tight spots, you’re on your own to handle difficult situations.
Torbet’s experiences have taught him that, even during team dives, sometimes you need to focus on yourself without distraction and without accepting responsibility for others; Andy experienced this in his Cave of Skulls explorations. Everyone needs to make their own decisions, trust their own gut feelings, and be vocal when things aren’t okay.
In his case, the Army trained him to put fears aside and get on with the job at hand. Andy specifically wrote in his book that, in the armed forces, the only option is to man up. When his teammates experienced difficulties during the Cave of Skulls dive, he decided to continue his adventure alone. [Ed. note: Global Underwater Explorers (GUE) does not sanction solo diving.]
“In situations like these—that not only require technical skills but also are potentially dangerous—it is easier to just look after yourself. But, in the vast majority of dives, you’re better off having a teammate. Being alone isn’t just less fun, but it also requires resilience that only a select few—and highly-trained—divers have.”
After he reached the end of the cave, Andy felt a moment of quiet satisfaction and peace. But, of course, his adventuring didn’t stop there. Andy’s current project and focus? Becoming a stunt double.
Managing stress as a stuntman requires individual concentration while your safety is in the hands of others. Torbet’s a bit uncomfortable placing responsibility for his safety in a crew, but he is learning to accept it. He said that he has a great deal of respect for this community, and it was a wonderful opportunity to work on a variety of films. “My last project, James Bond as 007 in No Time to Die, was an incredible experience.” I asked him if he could elaborate, but he said he was under a non-disclosure agreement and couldn’t say more.
Torbet is eager to keep doing these kinds of projects, and he explained that stunts in an action movie require a lot of rehearsal and coordination between different teams, performers, cameramen, and safety crews. It is all extremely streamlined, like a dance between crews. Any stunt person, whether in a blockbuster movie or a documentary, will report that planning is required in order to prevent life-threatening peril. Nothing is left to chance. For all these circumstances, preparedness is key (physically and mentally). Timing and self-confidence are paramount. And, like Torbet’s observation about diving, you save your life long before you start.
Why does he love being part of the stunt community?
“They are a real brotherhood, it’s a family atmosphere, and they look after each other. They are extremely motivated, talented, and self-disciplined people who want to get the most out of life. Although they are super adventurers, they also have the skills and bring their game up. On top of all that, everyone that I’ve met is a thoroughly decent human being.”
A Perspective on life
Torbet is constantly in motion, always growing. He recently got his master’s degree in Archaeology. His plan is to write his doctoral dissertation on studying caves. His diverse interests and activities are always driven by passion. He teaches that adventure is personal and that even by walking on the path others have taken, it is still possible to own your journey, to fill it with new experiences and feelings.
“Everyone is different, and what works for me does not necessarily work for you,” Torbet advised. For him, compartmentalizing is a way of dealing with his life experiences. What happened in the armed forces stayed there, and he doesn’t share it with his family or mix it up with his other activities.
I think Torbet’s secret is focusing on the moment. Taking pleasure from his job at hand, filling his time with projects and family. Teaching his kids about the pleasure of nature and freediving when he has spare time. As he told me on more than one occasion, “Your happiness is dictated by the people you surround yourself with.”
Fourth Element Wetnotes: My First Time-Andy Torbet
Read about Andy’s past adventures as well as his current projects at Andy TorbetProjects | Andy Torbet
Amazon: Extreme Adventures by Andy Torbet
Beyond Bionic Andy Tornet TOP 3: Andy Torbet from Beyond Bionic tells us his top 3, like his favourite foods, memorable moments and inspirational people!
Find Andy Torbet’s “close call” story in Close Calls by Stratis Kas.
I want to thank Andy for his openness and candor with me and the diving community. He was kind to me, letting me pick his brain. He is truly a gentleman. I really enjoyed our conversations. I hope we can drink a pint or two in an Irish pub in the future and go diving.
Carlos Lander—I’m a father, a husband, and a diver. I’m a self-taught amateur archaeologist, programmer, and statistician. I think that the amateur has a different mindset than the professional, and that this mindset can provide an advantage in the field. I studied economics at university. My website is Dive Immersion. You can sign up for my newsletter here.
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