Complacency kills - It's not just an empty threat!

[doctormike]

Yes, and this goes back to the line with "culture" in it in my first post above. BTW, I am p.... to have to admit that I can't raised my hand, for both reasons. And for a third, because of course, there is also skipping by mistake, since using a written checklist that you do not physically check off each item of, is a poor substitute. Better than nothing (think rEvo), but not foolproof.

Right, but from a logistical point of view it’s hard to have a diver geared up in their unit and then have them checking things off with a pen.

On the other hand, if you have a simple pre-jump list stuck on your controller and you commit to actually doing these things, it would break the accident chain. I don’t think that’s a poor substitute, I think it’s s good substitute.

I mean, if your concern is that people are going to look at a printed checklist and then tell themselves that they turned on the valves or did a pre breathe when they really didn’t, what’s to prevent them from physically checking it off and not doing it? People with electronic checklists sometimes just memorize the number of pushes it takes to go through the screens. You can’t help someone who is willfully negligent.

Maybe it won’t catch every conceivable problem, but it would have for the tragedy in Hawaii and the near tragedy described by the OP.

- Turn on valves
- Check SPGs
- Test MAV /ADV / wing
- Tun on handset and HUD
- Pre breathe (for at least a few minutes with your mask on or your nose pinched) and make sure you can hold a set point
- Check your bailout

 

[hroark2112]

I think everyone needs to find something that works for them.

Preferably before you almost die...just sayin’

 

[Schwob]

...just sayin’

Ha!
You certainly earned the right to "just say" that the hard way... don't do that again so...

 

[doctormike]

I think everyone needs to find something that works for them.

Preferably before you almost die...just sayin’

Yup! This actually brings up a really interesting discussion.

Scuba diving has no central authority, and since you are primarily risking your own life (although there is always the risk to a rescuer), there hasn't been any sort of organized effort to standardize diving practices. I know that RESA just released some standards for rebreather training, but that's for agencies, not for individuals, and it's not really binding. If you want to do a 200 foot bounce dive on an AL80, there really isn't anything stopping you.

So in the rebreather world, we talk about the "culture" that uwexplorer mentioned upthread. Ideally, if there are certain things that really are best practices without downsides, discussions like these will make them more likely to be done. That's why accident analysis is so valuable, and why people bother to chime in, etc...

In activities where large organizations are involved, and where there is a risk to others besides the people doing the activity, we do have formalized and standardized protocols. Each pilot doesn't get to use the pre-flight check that works for him or her. When I operated this morning, I had to run through a pre-op checklist, and I don't have the option of coming up with my own. As I mentioned, scuba is different, and no one can make you do anything, but we can still learn from industries that have successfully improved safety, by making certain things (like checklists) a part of the rebreather culture.

 

[uwxplorer]

I think everyone needs to find something that works for them.

That is the question.
Is this what, as an instructor, you would be telling your students (or implying): I am showing you guidelines, but then, when you are out there on your own, you do whatever you want, because I really can't impose anything on you?
Or: there is no way to cut corners, because those rules are written in blood. And if I ever see you cutting corners, I am rescinding your cert.
The latter is clearly not the way it works in the field, and this is all nice and fine as long as you don't have to attend your buddy's memorial, because then, the question becomes: what have I not done which could have prevented this screw up?
I am asking your buddies: what have you not done or said, that he could screw up so badly?

 

[gcarter]

Yup! This actually brings up a really interesting discussion.

Scuba diving has no central authority, and since you are primarily risking your own life (although there is always the risk to a rescuer), there hasn't been any sort of organized effort to standardize diving practices. I know that RESA just released some standards for rebreather training, but that's for agencies, not for individuals, and it's not really binding. If you want to do a 200 foot bounce dive on an AL80, there really isn't anything stopping you.

So in the rebreather world, we talk about the "culture" that uwexplorer mentioned upthread. Ideally, if there are certain things that really are best practices without downsides, discussions like these will make them more likely to be done. That's why accident analysis is so valuable, and why people bother to chime in, etc...

In activities where large organizations are involved, and where there is a risk to others besides the people doing the activity, we do have formalized and standardized protocols. Each pilot doesn't get to use the pre-flight check that works for him or her. When I operated this morning, I had to run through a pre-op checklist, and I don't have the option of coming up with my own. As I mentioned, scuba is different, and no one can make you do anything, but we can still learn from industries that have successfully improved safety, by making certain things (like checklists) a part of the rebreather culture.

I understand the sentiment, but a doctor is subject to the procedures of the hospital that provides the facilities you are using. Do a procedure in your own office, and there is nobody looking over your shoulder. Similarly, a pilot for an airline (or military) has to follow their employers procedures. A private pilot of their own plane can do as they please as they also do not have anyone looking over their shoulder.

The difference is that what you do privately will always see certain individuals turn their nose up at well thought out and established protocols. The ones you talk about who participate in these discussions, who look for ways to improve, to get better, are generally speaking not the problem.

 

[doctormike]

I understand the sentiment, but a doctor is subject to the procedures of the hospital that provides the facilities you are using. Do a procedure in your own office, and there is nobody looking over your shoulder.

Not really true. There are standards of care, and significant consequences if you don't follow them when a problem happens.

Similarly, a pilot for an airline (or military) has to follow their employers procedures. A private pilot of their own plane can do as they please as they also do not have anyone looking over their shoulder.

I'm pretty sure that FAA regulations apply to everyone, but I'm not a pilot so I don't know for sure

The difference is that what you do privately will always see certain individuals turn their nose up at well thought out and established protocols. The ones you talk about who participate in these discussions, who look for ways to improve, to get better, are generally speaking not the problem.

Right, that's the exact point. That's what people mean by changing the culture. You will never get 100% compliance with any protocol, no matter how well thought out and non-controversial. There is always going to be someone who will do their own thing no matter what. But by changing the culture, you make those people the exception rather than the rule.

For example - nitrox divers for the most part analyze their own tanks. It's drilled into your head in class, and you really aren't going to find many people here arguing that it's fine to let the crew tell you what is in your tank and just trust them. That's a cultural thing.

What hroark did here by bravely posting his accident report helped to move the culture a little bit towards everyone understanding the importance of not rushing and checking your PO2 before you jump. What Brian Bugge's widow posted on facebook did the same thing. It got a lot of people talking about the importance of checklists and not being distracted with cameras during training, etc...

So we should keep on posting and discussing these problems when they happen. There is no FAA or Joint Commission for us - we are all on our own. When we help to move the culture in the direction of safety, that's a good thing.

 

[gcarter]

Not really true. There are standards of care, and significant consequences if you don't follow them when a problem happens.

Not to belabor the point, but it is true. Regardless of potential consequences, there is nothing to stop deviations from standards of care if the individual chooses to ignore them. Normalization of these behaviors can easily occur with each successive departure that happens to not go wrong.

I'm pretty sure that FAA regulations apply to everyone, but I'm not a pilot so I don't know for sure

Again, the fact that the rules apply is not relevant to the idea that when there is nobody looking over your shoulder you can do as you please.

 

[hroark2112]

That is the question.
Is this what, as an instructor, you would be telling your students (or implying): I am showing you guidelines, but then, when you are out there on your own, you do whatever you want, because I really can't impose anything on you?
Or: there is no way to cut corners, because those rules are written in blood. And if I ever see you cutting corners, I am rescinding your cert.
The latter is clearly not the way it works in the field, and this is all nice and fine as long as you don't have to attend your buddy's memorial, because then, the question becomes: what have I not done which could have prevented this screw up?
I am asking your buddies: what have you not done or said, that he could screw up so badly?

As an instructor, I teach to the standards as set forth by the agency and the manufacturer. I would never imply that it is acceptable to take shortcuts or skip steps. Obviously, the consequences can be fatal.

My mother used to tell me that there are 3 kinds of men in this world:

• Men who learn by reading
• Men who learn from the mistakes of others
• The rest of the men out there who have to pee on the electric fence for themselves

Keeping that in mind, between my own experiences and the experiences I have read about and seen in person, I can hopefully impart some knowledge and help others learn from my mistakes and help someone else not make the same errors. If I can help just one guy not pee on that fence, it will be a good day.

 

[uwxplorer]

There is a book out there by Cousteau in which he tells about the lesson he learned from the first diver death on the Calypso. He essentially says that he decided that no risk would ever be taken in his future expeditions and safety would become paramount. I bet there would be consequences if a diver was caught doing some stupid things.
My insistence on culture is due to my experience that risky behavior is generally not called upon and probably most of the time not even noticed, whether by the potential victim or those who surround them. That, more than anything else, breeds complacency. Think of the opposite culture as "positive peer pressure". Why it is all but gone is a mystery to me but comes to haunt me when I think of those I knew who did not come back from their last dive.
My latest example is from my last dive, after a hiatus of a couple of months. I did not make any technical errors (although a thorough analysis of the dive would show that it was far from being a textbook one), but broke the agreed on plan to check out a free swimming wolf eel after reaching the ascent line. We came back fine, but it is not until my buddy jokingly referred to the event with others back on the deck plan that I realized the potential cascade of events that could have made things completely wrong.
I am just asking: what makes our lapse of judgment possible?