Hi lamont,
Nice post. I agree with you 100% if we are talking primarily about incident analysis. Incident prevention, on the other hand, requires a different perspective.
Using your chain-of-events discussion, we can illustrate this, for example:
I = A + B + C + D + E + F+ ...
... where I is the eventual incident and A to F are the various events in the chain-of-events, where A occurs before B and B occurs before C, etc. In other words, A causes B, which causes C, on down the chain.
If A equals a poor dive plan (in this case a poor entry and descent plan), and B equals physical over-exertion based on underlying fitness (a sub factor of B) and C equals CO2 build-up and then D equals shallow/rapid breathing and more over-exertion and CO2, and E equals serious fatigue and stress and then F equals abort the dive .....
What my post mentioned is that, in this (simple) case, a proper dive plan that minimizes the physical exertion to reach the descent line is designed to eliminate the subsequent "chain of events". In the example "abort dive" case in this thread, there would be no incident (abort dive) because the diver would not have been serious fatigued (and/or had CO2 build-up) and aborted the dive if they had entered the water and approached the descent line in a way that did not cause over-exertion (and excess CO2).
If A leads to B, which leads to C, which leads to D, E, etc. in a chain-of-events, and we eliminate A, we, by definition of "chain-of-events" also remove B, C, D, E, ... when discussing incident prevention versus an analysis of the entire chain. As mentioned, incident prevention is a different kettle of sea urchins than incident analysis.
Earlier, I opined that the underlying cause of this incident ("abort dive at surface") was a poor dive plan (for entry and approach to the descent line), which means that if this issue was removed (and there was a dive plan where the divers were not required to be over-exerted and then fatigued), there would have not been any CO2 buildup (in this particular chain), because the diver should (would) not have been fatigued.
As mentioned, I complete agree with you that all elements in the chain-of-events are factors in the final incident. On the other hand, if you eliminate a link at the beginning of the chain which causes other links, then the underlying cause, from a incident prevention perspective, weights much more heavily on the poor dive plan, in this simple case, versus the physiology of CO2 build-up.
When any swimmer is swimming without anything to hold on to, against strong current, and they have to over-exert themselves and become fatigued to get to the descent line, the entire incident of fatigue and "aborting the dive on the surface" could have been eliminated by entering the water in a way where the diver does not have to fight the current to get to the buoy at the descent line.
I guess one way to view could be in light of those old stories about the older man beating the younger man on the tennis court, not by the strength of his serves, or the quickness of his feet, but on conserving energy, strategically placing the ball to make his opponent over-exert himself, and then wear down his energetic tennis opponent.
Yes, we can recommend the diver to spend more time working on cardio, and hope to make him more fit to swim against strong current (that usually comes with more daily or weekly diving, step-by-step); which is always good; but in my view, it is generally better to plan dives that do not require physical over-exertion and fatigue because this is recreational diving and should be fun, not an exhaustive surface swim in strong current just to get to a descent line to begin the dive.
My gentle reply to you is that you may be overly generalizing in saying that "none of them [the events in the chain] are any more an underlying issue than the others", because in a chain-of-events, the earlier events lead to subsequent events, and therefore, the earlier events are certainly more of an "underlying issue" than the others, according to the theory of causality (cause and effect).