cdiver2:
Hi,
In all incidents and accidents, there is a chain of events that can be constructed that led to the end result, wherein changing any of the links (different decisions, different equipment, different circumstance, different luck) would have avoided the end result.
As noted here, there are several such links that were in the control of one or another person as decision points (and perhaps equipment, as noted above regarding signalling devices; and certainly luck, as exemplified by the boy scout rescue!).
Training and discipline strive to improve the number of good decisions that tend to break the chain of events that too often lead to tragedy.
Diver decisions when faced with equalization problems, buddy decisions when contact is lost, and boat roll calls all are key decision and action points in what is an all too likely set of events (probablity is really pretty low, but high enough to have caused risk mitigation procedures to be documented in most all basic training curricula).
At each decision point, a poor decision was made, moving you one step closer to a bad end. Remember that when you think that it is just a small risk to not follow a well-documented procedure ... you may be just fine, or you may be taking one step closer to a tragedy! Typically, each event in the chain becomes more critical (though that is sometimes not obvious from the middle of the chain).
Each decision carries a risk mitigation weight also (some are much more important than others). The boat roll call is a tier-1 risk mitigation: by the time you get to that safety procedure, if it is in fact needed, that is most likely because you are already well on the road towards a tragedy ... this is one of the last links in an accident chain, and one of the last opportunities to avert it.
As such, the failure to conduct a 100% effective and complete boat roll call every time there is occupancy change on the vessel represents an egregious failure of judgment on the part of the operator.
A diver is responsible for himself; a buddy is responsible for himself and his partner; the DMs / dive leaders are responsible for the divers; the captain is responsible for every soul on his vessel (and for not endangering others in the area, for that matter, and for following all laws and regulations applicable for activities engaged in). Each link in that chain of responsibiltiy carries more weight in the incident event chain decision making process.
In my opinion, the boat captain should have license revoked permanently, and the senior DM should have certification revoked. Some mistakes you only get to make once, period.
Succesful punative monetary judgment in civil litigation would be appropriate (very effective deterent for others who don't take their responsibilities seriously).
Lawyers come in all flavors (just like the rest of we poor mortal souls): the blood-sucking leeches that abuse the system; and the champions of victims who ensure sufficient redress to help the victims, and sufficient punishment to deter others from acting badly in future ... and all shades of grey in between.
I fear it is always hard to make and keep the right balance between those extremes, and you can't have enough of one with out some of the other. Sigh. Real life is so complicated ...
Cheers,
Walter
