"If Only..." By The Human Diver

[Mastow1]

The new documentary for the Brian Bugge accident has been released.

Another problem with not following the rules or making a mistake and not being called out on it is that it can then be part of a normal process. That then can lead to a bad chain of events.. Same happens in skydiving. You get lax, break rules, nothing wrong happens and then it becomes a part of your process.

Excellent educational presentation regarding the genesis and compounding factors leading to accidents. The critical take away for instructors and divers in this and the majority of incidents is that it probably would have been avoided if the diver had correctly employed a pre-dive checklist. Liberty realizes the criticality and includes a checklist in their controller program. When trainers and divers accept and convey this as a life-sustaining, do or die part of each dive, fewer divers will perish. Therefore our responsibility is to make the use of a checklist the mark of a proficient diver and stigmatize omittance as stupid.

 

[John the Pom]

Excellent educational presentation regarding the genesis and compounding factors leading to accidents. The critical take away for instructors and divers in this and the majority of incidents is that it probably would have been avoided if the diver had correctly employed a pre-dive checklist. Liberty realizes the criticality and includes a checklist in their controller program. When trainers and divers accept and convey this as a life-sustaining, do or die part of each dive, fewer divers will perish. Therefore our responsibility is to make the use of a checklist the mark of a proficient diver and stigmatize omittance as stupid.

I have a little background in Safety Engineering and, if I may, I had a couple of comments.

The modern System approach to safety and security assumes that people are fallible and errors are something to be expected. It views errors as consequences rather than causes, originating not in human behaviour, but in the conditions under which people operate. Since you can't eliminate human errors, the best approach is to build defences or try to mitigate the effects of those errors. Checklists have their place but if your system relies on individuals going through a checklist every time they perform a task and never making a mistake, then failures are inevitable.

Another important part of a good safety culture is an environment where people are unafraid to report / discuss mistakes openly, whether they led to an incident, or a near miss, or nothing happened. Those reports are vital to identify recurring errors that may grow into incidents. Shaming people for making mistakes tends to lead to the opposite culture, where people are afraid or embarrassed to openly discuss what went wrong.

 

[Celt]

Is there no warning that oxygen is not turned on ?

 

[KenGordon]

Is there no warning that oxygen is not turned on ?

No, but the handset and HUD will be red and showing low PPO2 for quite a while before the diver becomes unconscious. Noticing this ought to be second nature.

I am not sure if this was a first CCR course or not. If a first course it is one of the things the student is learning, having said that I have made a similar mistake on a refresher when I ought to have know better. Fortunately I had a competent instructor who noticed and gave me a low ppo2 card and had me debug the mistake like a drill.

What killed this bloke was not the mistake on the day, it was a bunch of things possibly starting with the initial try dive, open after training and first dives. I would guess he was more accepting of poor practice than he ought to have been because it seemed normal to bend or ignore good practice from the start.

 

[Angelo Farina]

No, but the handset and HUD will be red and showing low PPO2 for quite a while before the diver becomes unconscious. Noticing this ought to be second nature.

I have read that his CCR computer was in surface mode as opposed to dive mode. Does this prevents it from issuing a low oxygen warning?

 

[KenGordon]

I have read that his CCR computer was in surface mode as opposed to dive mode. Does this prevents it from issuing a low oxygen warning?

Mine would be red, I don’t know about the Liberty. Divesoft are generally sensible so I would have hoped it was very obvious.

 

[tbone1004]

I have read that his CCR computer was in surface mode as opposed to dive mode. Does this prevents it from issuing a low oxygen warning?

no, it was still trying to fire the solenoid

 

[M DeM]

Recreational diver / CCR-ignorant diver here...

Watching the documentary, it sounds like Brian was waiting on the tow line, with the instructor right there..

1) so was he not at the surface, waiting on the tagline? If so, is it not possible to take the mouthpiece out of your mouth and breathe air?
2) was there no air in his wings?
3) WHY do instructors let students into the water with cameras? I have seen this *multiple* times. Shouldn't PADI/SSI tell their instructors to not allow cameras?
4) Do tec divers not do buddy checks or was it just missed?

 

[lermontov]

its just demonstrates how cumulative error has such high potential to be deadly esp with ccr. very sad and a sobering reminder to have checks

 

[justinthedeeps]

This is the same reason we have things like BWRAF. Breathe from the reg, watching the SPG. The only way to confirm that your valve is open. How many people aren't doing that check properly? That could kill you too.

The check routine is the only thing protecting us from human factors. Nobody's drowning was inevitable. If I do myself in by skipping steps, please do not blame the butterfly that set off an avalanche or the guy who cut me off on the way to the dive.

A better case against the training agency would be to hold them accountable for letting a student enter the water without having done the checks properly.