By Kenneth Capek, MPA, RRT, CHT

How often have you performed a safety protocol such as a buddy check and was interrupted by someone asking a question or stopped to take care of a problem and then forgot to complete the check. Maybe you’re rushing because a problem arose which needed attention right before the dive. You may totally believe you completed the safety check at the time only to find out later that you did not. A buddy check or self-check is a "systems" mechanism created to ensure we don’t forget to check that our equipment is functioning and we have everything we need for the dive. The checklist system is great but what went wrong this time and why would someone think it was completed if it wasn’t?

You frequently dive in a local river at home with a mild current and handled it without any problem. Now you are on a trip and at a new river that looks exactly like the one at home. When you jump in you realize the current is twice as strong in this river and the higher slippery banks will make egress difficult. Then you see the waterfalls up ahead and you know you are definitely not in Kansas anymore. Why did we think this situation would be the same as the one back home? Sometimes human errors occur not due to neglect, lack of training or bad luck, but may be due to mental miscues.

We humans go through the day for the most part on "auto-pilot". We perform the same routines hundreds or thousands of times without really thinking about them. If my wife calls me at work and tells me to stop on the way home and get milk I had better write it on a post-it and place it on my car rearview mirror. If not, I will end up in my driveway when it finally registers that I forgot something. In addition, I would not be able to tell you anything about the trip home unless something significant or emotional happens like seeing an accident or someone cuts me off.

We go through our lives with our minds operating on a type of cruise control and it is part of our being human beings. The psychological explanation for this is that we create "situational models" in our minds. Laurence Gonzales writes about how this process works in his excellent article called "Why smart people do dumb things" (Adventure magazine August 2007). He explains that we form models of the world, as we believe it to be and use these pre-constructed models to function in that world, rather using the actual world we are presently experiencing. This clearly has a potential for danger and partially explains why smart people do in fact make dumb mistakes sometimes. He writes, " We code information in an abbreviated form for quick reference" which enables us to function efficiently. Once these models have been developed they require no thought to put them to use.” These models are sometimes constructed haphazardly, without good information and are based purely on our past experiences. What if the past experience we are referencing doesn't quite apply to the present situation.

There is a well-studied behavioral phenomenon, which says we tend to generalize about things in the future based upon about things that worked in the past (that familiar old river we jumped into). In addition, we tend not to notice things that are not familiar to our model. Like using old assumptions that don’t apply, this practice can result in unexpected outcomes. I did fine on that dive when my computer was reading low battery so I should be okay this time. Except this time the computer died completely and the situation very different.

Another function of our mind is to ignore things that are too common and no longer have significance. Can you tell me what that picture is hanging in the hallway you pass every day? Gonzales explains, "We really don't perceive the world most of the time. We take in perceptions through our senses and then pull up what seems like the most relevant mental model. We see, hear, smell and feel by analogy. This system allows us to move smoothly through the world without having to stop all the time to reexamine something we've already examined, but this efficiency comes at the cost of careful analysis". This brings us back to the issue of safety. Many of our models can get us in trouble when it comes to diving. We need to examine each situation as a new one. We can build elaborate systems to reduce risk but we still have the human element. Human error will always exist. We still must endeavor to minimize risk in every way possible but must not be lulled into a sense of security that we become complacent. Stay tuned in. Our world is not 100% safe yet our technology and systems mislead us into thinking that it is and everything is taken care of. Good reason for redundancy.

What can we do?

We can be safer and reduce the risks of diving in if we acknowledge and understand how our minds and their models work. The most important thing we can do is to get off autopilot when it comes to diving. It’s okay when doing basic procedures like clearing a mask but not much more. Procedures such as buddy checks do if fact work but you must also slow down the process and examine what you are doing. What if you are interrupted? I have found that when I do forget something back on land it was because I was in a rush. Boat leaving! Does the phrase "take a time out" sound familiar? It is simply a break in the fast routine of everyday operations to reexamine and think. Allow yourself time for a second thought, because first thoughts are sometimes not thoughts at all. Good time management and giving yourself time to ready your equipment prevents that last minute rush. Before you jump in off the back of that boat take a “time-out”; check your air by breathing on the regulator and looking at the SPG. Last time I was in Bermuda a husband accidentally (I hope) shut off his wife’s air and she didn’t do this check. Fortunately she got back on board the boat quickly and safely. Have you heard of the acronym STOP (Stop, Think, Observe, Plan)? In diving we have a similar recipe when faced with problems and nearing a panic situation: STA (Stop, Think, Act). First Stop, get off autopilot, this may be a situation you never before experienced so don't act yet. Think, see all your options and pick the best. Act, implement your plan.  I would add to this, take a slow Deep Breath, which actually helps to break the panic cycle. Your world will be safer when you are not operating on autopilot and just think how wonderful the world is when you are actually observing it. Slow down the pace. Just think how many accidents occur when you are rushed and autopilot is in high gear. When you are interrupted during a routine safety check, start over! Yes it takes time but ask yourself how important it is and what are the consequences if something is missed. In the world of diving that cost may be extremely high.