How important is armchair incident analysis?

[Spectre]

True accident analysis has it's place. However there really is no place for it in scuba diving, at least where we are currently. We have 'agencies', but we have no governing body to enforce the lessons leaned by true accident analysis. What's the point of boiling it down to the -actual- lesson to be learned when many of the accidents are just subtle variations on the same things that happen over and over and over again?

From what I've observed; there appear to be 3 types of people that want to take part in discussions about scuba accidents. There's the rubberneckers that just want to see what's going on, there's the 'not me' crowd that want to find the stupidest thing that happened in it in order to justify that it won't happen to them, and then there are those that wish to use it as a tool to learn to be more aware of the risks they personally undertake.

We have a number of understood rules, yet time and time and time again people chose to ignore some of them. We have people citing the lack of cave deaths in singles as justification that cave diving in singles is safer than doubles, yet they feel perfectly justified to strap doubles on their back and exceed their training. Time and time and time again there are accidents that can be attributed to the narcotic effect of nitrogen, yet we have people constantly feeling that they are good enough to dive while intoxicated.

If we want to boil it down to something that's actually -useful-. Just state 'they died because they couldn't get enough oxygen to the brain', which is the only true conclusion we can draw without making some assumptions. The lesson? Figure out how to keep your brain being fed oxygen. Now how you achieve that goal is something that you have to decide for yourself.

For me, personally? Let's see... there was Pete. Pete is dead. Do I know for an irrefutable -fact- that he toxed from the effect of sudafed and antihistimines in his system? No. Do I disregard my theory because it isn't proven fact? Sure, I can. hundreds of divers wake up in the morning, pop a couple sudafed and head over to the dive site and come back fine. Do I wish to be the person that ends up proving my theories? No. So I'll continue to be very aware of what I put in my body prior to a dive, and feel 100% confortable in my decision to thumb it if I feel I -need- to take something in order to dive.

There was Tim. Tim is dead. Did Tim really get complacent about his personal procedures because he was keeping an eye on someone he took into an environment that other person wasn't trained for? I don't know. And personally, I don't care. Why don't I care? Because I recognized in myself that I take things for granted when I'm focused on someone that has me as a buddy when they are pushing close to their personal limits. I recognized that there were dives where I never bothered to check my pressure gauge until we hit the upline. I recognized there were plenty of times where it could be conceivable that my left post was off and I wouldn't have known until I switched to it. I don't know, nor will I ever know, why Tim's left post was off... but I -do- know that if he noticed it was off before he donated his long hose, and turned it on, he'd still be alive today. Or at least he would have been alive after that dive. Do I care if it's a proven fact or not? No, because his death caused me to recognize complaciency forming in my diving, and smacked home the potential results.

So as far as I'm concerned, true accident analysis is useless for the scuba industry, since finding the truth does nothing but help people justify "I wouldn't have done that". The lessons learned from true accident analysis wouldn't be of any use, since people already blatently ignore the 'rules' that are currently understood. However discussions of an accident, theorizing about what might have happened, trying to fill the informational gaps to piece together a pausable understanding, for the personal use of learning about your diving, your risks, your tendancies....

... that's how we can honor the dead amoung us and let their sacrifice be not in vein, and let them live on in our memories and the changes their death enduced in us.

 

[TSandM]

I work in an ER, so nobody has to tell me about how much denial and delusion people are capable of.

On the other hand, this board has a LOT of lurkers and new divers.

When my husand was flying, we took the NTSB reporter. After a year or so of reading it, I realized that the majority of fatal light airplane accidents boiled down to one of two things: Running out of fuel, or flying into known or probably bad conditions (VFR into IFR). Knowing those things would help me to recognize when my husband might be making a bad decision. I think you can apply the same kind of thinking to diving.

As a new diver, I read reports of people diving off boats and being lost and spending a lot of time on the surface waiting to be found. As a result, I changed my behavior (made sure I had signalling devices). I think there are probably a lot of people who change their behavior as a result of what they've read about accidents and incidents. Not the people who are going to tie one on and then drive 70 mph -- you can't fix that kind of poor judgment. (And there is little of value to be learned from an accident that is a result of that kind of egregious stupidity.) The value, I think, comes more from the accidents where one or more decisions could have been made either way, and the way chosen lead to a bad outcome. In this sense, the best incidents to analyze are the ones someone survives, where the actual sequence is readily available. Second best are the ones where someone directly involved speaks up -- the diver's buddy, for example. At the very least, such analyses can cause someone to recognize that there are decision points that need to be considered very carefully. Who comes out of OW with the answer for all the difficult questions? If we did, there'd be fewer threads posted on SB!

 

[johno1]

I have been involved in a couple, but one significant one that comes to mind was a buddy separation in a wreck. I won't go into the details, but one diver ended up with a significant deco obligation that needed to be managed from the surface boat. Upon doing the investigation, we found that going through a detailed dry run on the surface could have prevented the incident. In our club we ended up changing some very relaxed protocols as a result.

I know I did not give much detail, it would take pages.

 

[Storm]

I You are only entitled to know about me that which I choose to allow you to know. Beyond that, you have no rights.

[Snip]

Lots of good stuff ....

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

... Bob (Grateful Diver)

Bob,

As you very well know, the majority of the details about dive accidents used in these types of discussions are usually provided by public domain institutes such as newspapers, news reports etc. In this context we have every right (unless free speech is a thing of the past) to know the details (as made avaiable to the puiblic), and discuss these topics. In the case where inforamtion is legally made available to the public (coroner, police, newspaper,. DAN reports etc) these same rights exist. What also should be considered is respect, and compassion for both the victum and the family of the victum.

I do agree that a private citizen's life is just that, private. Their right to privacy, and that of the surviving family should be paramount. However, it is entirely a different story when dealing with pubic domain information.

As to being sensitive to the family members, again I fully agree. Perhaps removing such discussions to an area seperated from the same area where condolences are being expressed is prudent. The deceased family would then be spared having to view the discussion (note here I use the term discussion and not analysis, as I feel the majority of these are just that discussions, not true analysis).

What do I hope to learn from these; situational awareness and perhaps help (if possible given the information made available) in recognizing how to avoid the same circumstances that lead to the "accident".

At who's expense; hopefully not the victum's family's. Which is why I would be more inclined to a seperate area for these discussion, perhaps with a warning as to the types of discussions so family members would not be blindsided while reading condolences.

Peace

 

[in_cavediver]

So as far as I'm concerned, true accident analysis is useless for the scuba industry, since finding the truth does nothing but help people justify "I wouldn't have done that". The lessons learned from true accident analysis wouldn't be of any use, since people already blatently ignore the 'rules' that are currently understood. However discussions of an accident, theorizing about what might have happened, trying to fill the informational gaps to piece together a pausable understanding, for the personal use of learning about your diving, your risks, your tendancies....

... that's how we can honor the dead amoung us and let their sacrifice be not in vein, and let them live on in our memories and the changes their death enduced in us.

Not so long ago, an individual named Sheck Exley took it upon himself to research the accidents regarding cave diving. He was one of the first to do an objective analysis of the facts available and attempt to draw conclusions regarding what likely happened. The result was a pamphlet he published "A blueprint for survival". Even though Sheck died in an accident himself, you can still buy the pamplet he wrote today. Also, if you notice, many incidents he himself included are incomplete in detail, yet still it was possible to glean the most likely scenario.

Now, what can we learn. Accident analysis does have its place and the best person to do it is someone who has like goals and agenda. Lets face it, most 'groups' would have the same goal, to try to figure out what happened. The problem is most 'groups' would have a different agendas. Be it for paying claims, family members protecting the image of a diver etc.

My agenda is much simpler. Although I may feel for the families of any victims, the conclusions I draw should be purely objective and if it turns out someone screwed up royally, then my conclusions should reflect that. I really only care about what happened and what was the most likely chain of events for the incident. I would then look where normally accepted practices and my practices would break that chain of events. I would also be interested in the deviations from the normal practices that may have played a role in the chain of events.

The big question is this. Does SB want to host an objective forum for accidents that may involve individuals clearly stating that one causal factor was a major mistake by the victim? This may irritate inflame or disgust the any viewing family members but that doesn't mean to original comment was not an accurate or appropriate conclusion to draw from the facts. If SB does not want to host such an exchange, which is well within its rights, then a true accident analysis approach to this would be quite hindered. There are other locations on the net you can discuss these events.

Mike

 

[lamont]

stop telling me what to do.

we have two different goals, and i acknolwedge that your goal is worthwhile.

i just don't call it accident analysis; that, to me, is something else entirely.

I'm fine with not calling it accident analysis. But anything on this board which is not either just wishes/prayers or what you actually call accident analysis is suppressed.

of that which you do not know, say nothing

And that's what I disagree with.

I can deal with ambiguity over the truth and over the certainty that something happened by discounting how much weight I give it, but I still consider it.

as for your analysis, how do we know they made it to 20 feet?

were the bodies recovered? any gear recovered?

Bottoms timers were eventually recovered.

 

[MXGratefulDiver]

Bob,

As you very well know, the majority of the details about dive accidents used in these types of discussions are usually provided by public domain institutes such as newspapers, news reports etc.

Actually, they are not. Dive accidents are notoriously underreported ... or reported so badly as to provide meaningless data for analysis. For some well-publicized examples on this board, search for the terms "Wayne Sargeant", "Tulio", and "Zak Jones".

These are either former ScubaBoard members or people who were well-known to ScubaBoard members. In each case, the ensuing discussions lacked one thing of significance ... details around what actually happened. In these cases, there was significant speculation ... 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. In the more recent cases of Rob and Kimber, there has been significant 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.

As to what you read in the papers ... it's typically written by a non-diver who doesn't even understand that people don't normally scuba dive while breathing from "oxygen tanks". At best, the information is misleading and incomplete. At worst, it's so out of context as to be meaningless.

In this context we have every right (unless free speech is a thing of the past) to know the details (as made avaiable to the puiblic), and discuss these topics. In the case where inforamtion is legally made available to the public (coroner, police, newspaper,. DAN reports etc) these same rights exist.

OK ... show me some reliable data from those sources on the accidents involving the people mentioned above. If you can do that, I'd be happy to concede your point. If you can't, I'll ask you to consider mine ... that these discussions occur in the absense of reliable, factual data and typically degenerate into blamestorming ... which serves no useful function whatsoever.

What also should be considered is respect, and compassion for both the victum and the family of the victum.

And how does second-guessing a victim's actions show either respect or compassion?

I do agree that a private citizen's life is just that, private. Their right to privacy, and that of the surviving family should be paramount. However, it is entirely a different story when dealing with pubic domain information.

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.

As to being sensitive to the family members, again I fully agree. Perhaps removing such discussions to an area seperated from the same area where condolences are being expressed is prudent. The deceased family would then be spared having to view the discussion (note here I use the term discussion and not analysis, as I feel the majority of these are just that discussions, not true analysis).

As someone who's been involved in these discussions ... until the day I chanced to have a discussion the daughter of one of the deceased ... and has watched them evolve over the past few years ... I have seen very little in the way of analysis.

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.

What purpose does that serve?

What do I hope to learn from these; situational awareness and perhaps help (if possible given the information made available) in recognizing how to avoid the same circumstances that lead to the "accident".

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?

And what of the accidents that were just that ... unforseeable circumstances that occurred despite the adherence of safety protocols and practices. What will you learn ... that **** happens?

At who's expense; hopefully not the victum's family's. Which is why I would be more inclined to a seperate area for these discussion, perhaps with a warning as to the types of discussions so family members would not be blindsided while reading condolences.

It's been my experience that family members are often seeking information and solace ... and have no idea of the content of a thread before they read it. 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.

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)

 

[lamont]

How many of y'all have become better at other endeavors ... such as driving a car ... by analyzing the accidents of others?

Well, my step-brother hit a pallet in the middle of the road doing well over the speed limit and wound up in a guardrail when I was in high school. That led me to some thought about my own practices of speeding around corners...

 

[HowardE]

I'm fine with not calling it accident analysis. But anything on this board which is not either just wishes/prayers or what you actually call accident analysis is suppressed.

I agree with this also...

so can't there be 3 places to discuss accidents?

1) real hard facts - data and factual info only
2) Condolonces for the party involced in 1.
3) Place to discuss scenarios - thought up - possibly because of 1. but where names and references to actual instances would be omitted?

 

[lamont]

I agree Bob... it's usually more of an excersize in one upmanship. Many want to appear to be the most indignant about the way the victim (or their buddy) must have caused the accident. It's just a variation of the "Stroke du jour" syndrome.

Often you get the feeling that they truly feel that "It couldn't happen to them". Which is true right up to the time it actually happens to them.

you actually slander everyone who believes in openly discussing accidents by statements like that. can you point out where i've made any indignant statements blamestorming fault on the victim or buddy, or where i've been suffering from "it couldn't happen to them" syndrome in anything that i've posted on an accident? if not, then stop painting everyone with such a broad brush.