How important is armchair incident analysis?

[Thalassamania]

As someone who was paid, for a decade, to perform "armchair" accident analysis I could, if I had to, create a rather long list of things that have changed in all of our diving as a result of such analysis. And now having BBS like this brings a "wiki" element to the analysis that may run about in circles for a while but that, to the best of my observation, settles down into a consentual model in time.

And as for speculation, it's a fine line between useless speculation and a complete critical path failure analysis. Keep on speculating, but not expectorating.

 

[H2Andy]

Bottoms timers were eventually recovered.

so both bottom timers were found by themselves? with no sign of the
bodies nearby?

what kind of straps did they have? were the straps cut?

how far away from the scene of the accident were the bottom timers found?

where were they found, physically?

 

[Storm]

…much of which could be correctly called "blamestorming" ... involved, and not much, really that was based on any established factual information beyond the death itself.
…clamour by people who feel it is their "right" to know the details of the accident ... despite the request of family that they not speculate as to what happened.

I have not been involved with those particular discussions, and in fact if you look at the last such “accident report” I posted in, I was asking for calmer heads and more compassion for those directly involved. I very much agree with many of your points; especially when it comes to “blamestorming”. As to the disrespecting the family’s wishes, shame on any who did this.

As to what you read in the papers ...
Again ... the very thing that makes these discussions so self-defeating is the LACK of public (I hope that was a typo on your part) domain information. And in the void created by that lack, the armchair experts usually supply their own.

YUP that would be a typo of the most grievous kind. As to what the papers report, agreed. Most often the have no real knowledge of the sport, and tend to err on the side that allows them to sensationalize the article. But discussing these in a civilized and compassionate manner helps some put the incident in context to their diving, and helps some in their grieving process. Again there is no place for “blamestorming”, or disrespect for the victim or the victim’s family.

A perfect example is the recent TDS thread about Kimber ... that rather quickly devolved into a slam-fest against the guy who organized the dive, despite the lack of information that said he had anything to do with the accident at all.

I am not familiar with this particular incident, and very rarely stop by TDS. The few times I’ve been there were as a result of looking into an incident and my stomach was quickly turned by the rampant poor manners and disrespect that I witnessed in some of their threads.

Can you not learn that from other sources?Do you not think that standard protocols have been developed for a reason? And do you think that all such accidents occur because the victim did something that was "avoidable"? Typically, diving accidents are the culmination of a series of errors ... either in protocol or judgment ... that compound to create the situation. A "chain of events", as it were. Can you reasonably ever expect to expose yourself to the same chain of events? And would you not already know enough to either break the chain or not put yourself in that situation in the first place?

I can and DO learn from many sources including instructors and very experienced divers, such as you, through my own experiences, through independent study, post dive analysis, and yes even some of these accident discussions. You have the advantage of being a very experienced diver with a wealth knowledge garnered from your experience and training. Per haps there is little value for you in these discussions. For some of us newer to the sport, reviewing the discussion, (including some of the hypothetical situations) can help us put some things into perspective, and even learn a few situational things to avoid.

For example, it wasn’t until I read about a diver who got his dive knife entangled with his own wight belt while dropping it, that I moved the position of my dive knife. Strangely enough several DIs and DM failed to mention that I was wearing my knife in a manner that could allow this to happen.

I also, having read them, place very little value in the RSTC and some of their standard protocols. They are baseline, but in my opinion could be developed a lot further.

It's also been my experience that no matter how well-intentioned a discussion, there will always be someone lacking the social skills or compassion to keep the discussion in proper context. Most folks who involve themselves in "accident analysis" discussions are really just trying to impress everyone else with their superior knowledge ... and really don't give too much thought to how it will impact the loved ones of the victim.

As I said, earlier, compassion and respect should be paramount. Second guessing someone’s actions or “blamestorming” is not the same as discussing the actions that were documented, the situation that lead to the incident, etc.

That being said, and with no disrespect to the victims and their families, now a days we are far to PC in some of our dealings with accidents and analysis. We cry out ‘Ban cell phone in cars’ after it becomes known that the driver was talking on the phone when the accident occurred. We blame the presence of the phone as it is gentler to the family than to simple say “driver error.” Heaven forbid that we can admit that we are mere mortals and thus prone to error. This is not to say that the cases you are referring to fall within this frame of discussion. It’s merely an observation of how, often in our efforts to spare the family any more pain, we will sugar coatthe situation or actions taken during an accident to spare the family and furhter grief. Afterall, no one wants to known as the family of the guy who made the mistake.

For all of these reasons, I think the potential drawbacks of such discussions far outweigh the potential good they might bring to the community.
... Bob (Grateful Diver)

Perhaps you are right, but then I get to thinning the old line “if it saves just one life…”

Peace

 

[lamont]

so both bottom timers were found by themselves? with no sign of the
bodies nearby?

no, bodies were recovered, with bottom timers/computers -- and of course flooded RB units, so no way of knowing what was in the gas they were breathing or the condition of the scrubbers.

 

[H2Andy]

see?

you need a minimum of information to start working. below that threshold,
there's just no point bothering

it took some prodding, but your knowledge of this situation has to be
fairly solid before you can start the work

 

[lamont]

see?

you need a minimum of information to start working. below that threshold,
there's just no point bothering

it took some prodding, but your knowledge of this situation has to be
fairly solid before you can start the work

Speculation on one diver having an issue and the other diving toxing led me to consider reactions to a buddy having an issue at the 20 fsw stop though. I have no clue what actually happened in the incident in question, but I know I'm going to try to remember to get on my necklace if my buddy drops...

 

[Scuba]

I agree ... but that's not accident analysis

I believe I as well as others have given examples of what accident analysis entails. It appears some believe that without all the relevant facts accident analysis is not possible. That it turns into useless speculation and hypothetical possibilities, but not so if focus is maintained. Gaps in known facts can often be filled to a high degree of probability. Depends on the evidence. The fewer the known facts the more difficult this becomes, to the point of irrelevance regarding reaching a highly probable determination. See my math example in an earlier post. If I have given the impression that it is going off on a wild goose chase, I'll unequivocally state it is not. What is accident analysis to you and what does it entail?

I disagree ... we all interpret facts to suit our particular perspectives on a given topic. We all delude ourselves by ignoring or rationalizing that which does not fit our preconceived view of the situation.

I think this is mostly a case of you call it tomatoes, I call it tomatos.

I think this is a good example of delusion. How many people, really, will be helped by these discussions? How many people will be hurt? And to what degree? How many people already reject common-sense diving safety practices out-of-hand ... without giving much real thought to why they might want to change? Frankly, I see it all the time ... even by those who are clamouring for analysis of every accident they read about.

I'll take the potential to save lives and prevent injuries over the potential for hurt feelings and its complications, which can indeed cause injury and death in extreme cases. If this makes me delusional to you, fine. I consider delusional to be one who believes that which is contrary to evidence. No evidentiary contradiction visible here. No delusion. But this could be an illusion. LOL Many people do reject common sense diving - but, what's that got to do with the price of tea in China?

You want accident analysis? Here's mine ... the majority of diving accidents are the result of two things ...

1). People ignoring what they were taught in their classes, and violating basic safety protocols.

2). People thinking that their skills are better than they actually are ... and getting themselves into situations they don't know how to get themselves out of.

Most of the accidents I have first-hand knowledge of boil down to one or both of those two things.

This helps me understand where you're coming from. I see it a little more complex, with many more nuances than - human in water, stay out. Just trying to illustrate a point to a rdiculous extreme.

Well, here's my point ... what makes people think they have a "right" to know the details of any accident

I agree, there is no such right in this sport. Public domain, right to discuss such whether you, or anyone else likes it is a right in our nation. At least I hope it still is. Personally I can respect a request from relatives or injured person not to discuss it. But if the info becomes public domain, I can not blame those who wish to exercise their right to discuss it in a responsible manner. Rights do come head to head at certain junctions. We either find ourselves on one side, the other, or the sidelines.

For the most part, people don't learn from discussions about accidents ... because those discussions invariably turn into "blamestorming", where facts are secondary to an in-depth analysis of "what I would have done". And second-guessing an accident situation is much easier from the safety of a keyboard than it is in real life, where you may be stressed, narc'ed, or dealing with problems unrelated to the dive itself.

Blamestorming may be common, especially when you consider placing blame on the operator is immensely helped along by the common practice of denial, defensiveness, or an attempt to make it a taboo. Unless they are using a computer, in which case they are damned for eternity. LOL Letting the chips fall where they may is an integral part of accident analysis. If the evidence doesn't warrant the point be made, it is often easy to point that out. Dismissing and ignoring the conclusion derived from a good analysis, which will bring forth all highly probable and definitively known contributing factors, is done at a reviewers peril. I do understand the position of those who believe good analysis isn't possible here. I disagree, provided people provide, not withhold, sufficient evidence. If the parties involved subvert the analysis by playing defense they can't blame the process. Often times we just don't have enough evidence to work with, or there is much less than is known to some. I won't speculate as to the reason why. LOL

Again I ask ... what do you really hope to learn? And at who's expense?

Good question. I'll give you a good answer. I hope to learn that which I may not have known, missed, ignored, forgotten, etc., to help keep me safe and sound at the expense of those who have already paid the price. A price whose cost sometimes continues to rise after the accident, regardless of what I do. The cost may further increase to those aggrieved with the addition of a perceived painful analysis. And the cost can also continue to rise for other divers by denying them the option to examine the accident. On the other hand there may be profits to be gained by those seeking profits. It's a complex equation. Often times a terrible price has been paid at a very high cost. Properly done, without violating other's rights, the potential resulting analysis has potentially more upside than downside. A point of disagreement here amongst board members.

Unless you have sufficient evidence to make a strong case against those of us who share a similar view, which you or others have not presented except as relates to specific cases, please respect it, change the channel, do not attempt to shut it down for those who disagree with you. This is also where we have a fundamental difference of opinion.. Live and let live.

 

[shellbackdiver1]

My main goal, call me selfish (its your right to do so) is to protect myself and fellow divers that I chose to go under the water with. Therefore, I read most of everything that I can find that concerns scuba diving mishaps.

For question one: The answer is yes. As a collective whole I have learned that its always diver error that caused the persons death. If you are in poor health, dont dive. If your equipment is faulty, dont dive. If you forgot how to use your equipment in an emergency, dont dive. Dont have a back-up plan, dont dive (and what is a plan without a back-up plan anyway?). Dont know your procedures, dont dive. Thinking about diving somewhere where you should not, Dont dive. Period...Diver error always.

For question two. Yes. Near Miss report....what is that? It's arm chair analysis. In my work environment safety is priority one. . Everyday safety meetings are held to discuss near misses from the previous day....What if, could have resulted in this, so lets not do that again.

Question three....all aspects of diving interest me. I also read most of the photography section of this board. If that makes me a rubberneck to look at others pictures and read about the camera settings then so be it. Im a rubberneck