Many divers, probably most divers, accept that diving can be truly dangerous. Of course, from time-to-time you’ll probably bump into someone who tells you and, most importantly, themselves that the risks associated with diving apply only to other people and not to them, but the majority of us are supremely aware that the Rottweilers can hit the fan on any dive, at any time, and for any number of different reasons. So it seems odd that there is so little mention in diving books and student manuals of the one “behavioral fault” common to the majority of dive fatalities.
Every year, the Diver’s Alert Network releases its report on diving incidents, injuries and fatalities. This is, in my opinion, the most valuable piece of data collection and analysis done by any organization within the dive community. It makes for compelling, but somewhat depressing reading. For example, in its 2010 report, it shares with us that there were 144 scuba-related deaths reported world-wide.
If we were to summarize the factors that contribute to dive fatalities, at least those in DAN’s report, we’d find four categories.
- Poor health (divers being really out of shape, on meds, ignoring common sense and diving with existing ailments or injuries).
- Procedural errors (things like not analyzing breathing gas, diving a rebreather with dodgy oxygen cells, running out of gas, etc.).
- Issues with the environment (getting into trouble because of changing conditions, like currents, visibility and the like).
- Problems with equipment (particularly serious in the world of rebreathers, but also including situations where a piece of kit goes pear-shaped and the diver freaks out and panics).
However, it seems to me that there is a fifth to add to that list, and its influence seeps into and significantly colors each of the other four. The Normalization of Deviance describes a dangerous facet of human nature. It goes something like this: We do something that does not follow the accepted (and acceptable) rules or guidelines – for example, we skip certain steps in a “standard” procedure because it saves time. The trouble stems from the unfortunate fact that we get away with taking the shortcut. Then, believing it’s safe to make the same safety shortcut next time around, we do the same thing… we ignore safe practice, established safe practice. In the absence of things going totally pear-shaped, our deviation from normal practice and safe procedure becomes a new acceptable norm.
The term Normalization of Deviance is from Diane Vaughan’s book on the Space Shuttle disaster, In that book, The Challenger Launch Decision, Vaughan, a professor in Columbia University’s Department of Sociology, points out that the component failure that contributed to the loss of the Space Shuttle, and the deaths of seven crew members on January 28, 1986, was predicted before the launch. The risks were known and documented!
She explains that normalization of deviance within NASA and Morton-Thiokol (the company that manufactured the solid rocket boosters (SRBs) used to propel the shuttle into space), allowed a recognized design flaw to be ignored. She writes: “As [NASA and Morton-Thiokol] recurrently observed the problem with no consequence they got to the point that flying with the flaw was normal and acceptable” In essence, flight plans made no allowances for a known issue with the SRBs.
This deviation from best practice resulted in what Vaughan termed a: Predictable Surprise. Eventually, luck ran out, the component failed and the shuttle disintegrated 73 seconds after launch killing five astronauts, two payload specialists, and grounding NASA’s shuttle program for almost three years.
Normalization of deviance – and the predictable surprises that follow – are part of that catch-all phenomenon too often observed during the accident analysis that follows failure of any high-stakes, high-risk endeavor. We call that phenomenon: Human Error.
Certainly normalization of deviance shows its ugly face in diving. Often. A classic example is the double deaths of Darrin Spivey, 35, and Dillon Sanchez, 15 on Christmas Day 2013. Spivey, certified only as an open-water diver, took Sanchez, his son, who held no recognized dive training or certification at any level, to try out new equipment, Sanchez had received as a Christmas present. For that tryout dive, they visited the Eagles Nest cave system, which is situated within the boundaries of Chassahowitzka Wildlife Management Area, Florida.
Spivey and possibly Sanchez were aware that they had no business attempting such a highly technical cave dive without specific training in cave, decompression, and trimix. The Eagles Nest, also called Lost Sink, is known justifiably as a very advanced, highly technical dive. There is even a huge sign at the water’s edge proclaiming such.
And it’s no secret that such an advanced deep dive demands respect, and training, experience and planning. Especially since the top of the debris cone directly below the system’s rather tight vertical entrance is deeper than the maximum sport diving limit. Anyone wandering in there by accident, would very soon realize the magnitude of their mistake and get the hell out of dodge… well, most would.
But Spivey and Sanchez had broken the rules before and gotten away with it. The pair had, according to records and the later testimony of family and friends, dived several North Florida caves including the Nest, and walked away Scot free. Their luck held.
Like NASA and Morton-Thiokol, Spivey and Sanchez had normalized their deviant behavior, and until Christmas Day 2013, everything was fine. Their predicable surprise was that both father and son drowned.
We all take shortcuts… Certainly I have, and I am sure you have too. If we have done so with dive safety, we’ve been lucky and have gotten away with it… up until this point at any rate.
Because of the regularity of dive fatalities and the metaphorical wake-up whack on the side of the head that these accidents can deliver, stopping the normalization deviance should be a breeze for divers. It should be simple for us to stop taking safety shortcuts. But I don’t think the dive community as a whole is particularly vigilant on that score.
Dr. Petar Denoble, DAN’s research director, writes: “While each accident may be different and some of them occur in an instant, most accidents can be represented as a chain of multiple events that lead to deadly outcome. Removing any link from that chain may change the outcome.”
I’ll put myself out on a limb here and say that if the dive community, especially dive leaders such as training agencies, instructors and other dive pros, could put greater emphasis on the pratfalls and consequences associated with the normalization of deviance, it might help to lessen the unfortunate tendency of some divers to depart from established best practices… We would in essence, be removing a link that shows itself in many chains of error. And we might see diving fatalities shrink: perhaps not to nothing, but at least shrink a little.
We will never change human nature, and never eliminate human error; but we can help to create a culture of responsibility based on a realistic review of what kills divers.