Student lost - Seattle, Washington

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This has to be one of the most unprofessional and shortsighted comments that I have read in some time from a "professional" in the diving industry.

Wow. I do hope that I miscommunicated. As someone who has been a military flight instructor trainer, flight safety officer and instructor trainer of such, as an Advanced Aviation Accident Investigation Trainer for the last 20 years, I am following the EXACT procedure used in military and civil aviation. The primary difference is that root cause is often not found because there's no budget in the industry to really do it, and LE efforts often stop once foul play is eliminated.

you discuss implementing increased policies, procedures, and further financial burden on your students based on what you think may have contributed to the incident instead of making corrections to your current procedures grounded on factual information.
I never advocated any of those things, especially financial burden. What I said was, I need to think and evaluate what I am currently doing, and decide whether I am still ok with my approach when new information is added.

t doesn't matter if the investigation shows the mix in the tank was bad or that her first stage regulator failed, you would rather focus on adding more lights to a diver so they can be seen better at night.
No, I used the lights as a quick example. The cause of her incapacitation has zero evidence, yet, so right now there is no point in looking at that, for me. I have already considered all the causes of incapacitation that I am aware of and have mitigated them as best I can. I expect that her cause will be one of the known ones, if we ever find out, and if not I will add it to the list and see what effect that will have on my diving.

You focus on the victim and if you happen to notice a light that's fine but you approach the dive not considering a light. If the recovery diver is focusing on the assumption that "there should be a light visible", they may swim right by the victim and not see them because they are focused on finding light and not the victim.
Having no experience as a recovery diver, that is helpful info to have and will definitely factor into my evaluation, thank you.

Truly knowing the actual cause of a dive accident and deciding if appropriate changes should be considered is vital and extremely important.
I agree completely, however in the dive accident world, it is astounding how often the final root cause is never truly established.
Please let me be clear, I never meant to imply that knowing the actual cause wasn't important. What I meant to convey was that, if I have a list of 5 things it might have been, and the actual cause is one of those, then I am ok with that since the actual cause is being addressed in my own diving, even though I don not know exactly which one it is. For example, the Rob Stewart case has had no final decision on cause, but the thread on SB and other discussion has narrowed it down to 3-4 possible causes, all of which I have considered in my risk mitigation matrix.

Just throwing corrective measures at the wall to see what sticks is not helping make you or your divers any safer and you are inflating your own ego as you are making assumptions on what might have happened and then implementing changes that you think are required based on your opinion.
Ego has nothing to do with it. I assess the risks, using various risk assessment matrices as required, then decide based on the final evaluation how I should adapt my diving practices based on discussion with peers, with senior folks and also my own judgement. When new information comes up that I haven't considered, such as the "rescuers couldn't find a light" part, I incorporate that into my matrix and decide whether or not I should change my approach.
That isn't ego, that is the bare minimum any instructor should be doing when confronted with new (to them) information, in my opinion.

t is difficult to force change on those that have never experienced the issue so you must be careful
I agree with the sentiment I think you are expressing, but I do that all the time. When I have a new student, I "force" procedures and such on them that they haven't experienced. Diving a long hose on tech courses for example, very very few divers on an intro tech level course have ever had a gas donation in real life, never mind in a restriction where they need the length. I have never had a mask loss under water, nor have any of my students. I (and the standards) make them carry a spare.
There is also a difference between force and encourage and discuss.

NHTSA and NTSB, for example, meticulously investigate and analyze incidents in order to provide recommendations on changes based on the actual causes of the incidents.
I did say that only entities with a professional interest will pursue down to a final cause, which those agencies do have.
Prescribing change based on imaginative speculation may lead you to overfitting your reaction to a fictional narrative, resulting in a false sense of security.
It could, I guess, except the very last thing I have as an instructor is any sense of security. I live with the awesome/awful responsibility that I have toward those under my care. I have been a CS/HTE instructor for over 20 years now (Critical Skills /High Threat Environment) and if you care at all about your students that carries a lot of weight on your shoulders. I have had 3 former flying students of mine die later in their careers, in incidents that had nothing to do with their training, and I still wonder and worry to this day whether I could have said or done anything that would have made a difference to the outcome.

But you should not pretend that your solution will address the actual cause of the incident,

I think I understand what you mean, but let me clarify what I mean. Lets say that in an accident, we as a community can narrow down the cause to one of three things. If I address all three in my approach then I have addressed the true cause, even if I never know which cause it was.

which you apparently don't care about.
Believe me, I care a great deal, but the reality is that in diving we very often don't know the real causes. I can live with that, reluctantly, as long as I have done everything I can to safeguard my students and myself based on whatever information I do have. I prefer my approach to the one I often hear, which is "when we know what really happened, then I will look at it" and then nothing ever happens.

I hope this clarifies my position, it is industry standard in industries that care about their losses, but I am fully aware that I am not always the best at conveying my thoughts clearly.
 
there's no budget in the industry to really do it

No budget? Or no willingness to publish the results of investigations?

What astounds me is that people think that a self-regulating industry works. The fact that so little information (or absolutely none) is disclosed after fatalities is one indicator that this self-regulation is a joke. People think that agencies being part of the WRSTC means something, and look down upon the DIR agencies for not being "certified" despite their training standards and requirements for instructors and students alike are stratospherically higher. It blows my mind.
 
No budget? Or no willingness to publish the results of investigations?
My guess would be a bit of both, sadly.

It blows my mind.
I have a very close friend who is a member of the RSTC and attends all the meetings. The discussions and things that happen at those meetings would melt your blown brain.
 
I have a very close friend who is a member of the RSTC and attends all the meetings. The discussions and things that happen at those meetings would melt your blown brain.

Based on the guidelines published, I believe that.

I wish that the industry would take fatalities more seriously.
 
Even if they had a budget, they have no jurisdiction. Although there are public records, they are not as public as one thinks.

The Cave community is a bit wdifferent case.
What do you mean agencies have no jurisdiction? They conduct investigations but never disclose them.

I don't see why the recreational dive community has to be different than the cave one.
 
What do you mean agencies have no jurisdiction? They conduct investigations but never disclose them.

Do they have authority to disclose their findings?

And do they do this for every accident?
 
Do they have authority to disclose their findings?

And do they do this for every accident?
Can you (or anyone) cite a law that prevents them?

I have yet to see a report disclosed by an agency.
 
Can you (or anyone) cite a law that prevents them?

Perhaps their lawyers advice, and a non disclosure agreement in the case of a settlement.

I doubt that they investigate any accident that does not have the possibility of including them in legal action.
 
Perhaps their lawyers advice, and a non disclosure agreement in the case of a settlement.

I doubt that they investigate any accident that does not have the possibility of including them in legal action.
That's why I don't think agencies who refuse to disclose findings take diver safety seriously. They are only interested in maximizing profits. As I've said many times, some people have to be allowed to die.
 
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