Training Scuba Ranch TX Diving Accident

[kammel78]

What I don't know is why her fins would not fit well. Generally, I know shops would require basic equipments to be bought, like mask, snorkel, fins. But this was something she complained about, I was told.

Shops allow OW class in rental gear, including mask/fins/snorkel. Charge an extra $50 for it. Equipment is a bell curve, most inventory is in the most common sizes, opposite ends of sizes get less inventory, i.e. kids and very large adults. Usually first come, first served so kids get stuck with too large BCDs, plus sized divers get stuck with wetsuits that are too restrictive.

Rental gear is often so very, very old and abused, i.e. full foot fins with torn foot pockets, BCDs with velcro that won't stay attached, don't even get me started on masks and regs.

Here's where story gets a bit muddy. I was told that they lost her on the initial descent. Obviously, accountability wasn't there to ensure everyone made it to their designated area. Why I feel this is a bit muddy is because when rescue efforts were underway, the frantic person that was driving around asking for help told me that she was last seen with 1050PSI. This doesn't quite add up. How did they know her pressure when they lost her on the first descent? Maybe they did account for her and lost her later? maybe lost her on subsequent descent, where they asked her for her pressure before descending?

I was also told that sense of urgency wasn't there by Scuba Toys when they realized that she wasn't with the group. They disregarded it as not a big deal and kept going with their usual business. After some time have passed, they did report the missing girl, but even then, they weren't really too concerned. Obviously, as more and more time clicked by, that's when things seemed more real and that's when they were expressing concerns.

So, if it was Dive 1 of Day 2, they likely reused a tank from the day before and knew the pressure. Or it was initial descent on Dive 2. Or they were on their "graduation" dive, which would also explain their nonchalance towards finding her. I've heard instructors on multiple instances say something to the effect of, "you're a certified diver now, if you die that's on you". On my OW, I was told to go "dive away" in Athens with 5' vis never having a single guided dive the entire weekend. Only 3 of us in the class opted to do a "fun" dive. 1 of them got to the houseboat at whatever depth, freaked out and bolted back to the surface. Diver 2 would have too, but that was my wife and she wasn't going to leave me alone.

 

[texfox98]

Shops allow OW class in rental gear, including mask/fins/snorkel. Charge an extra $50 for it. Equipment is a bell curve, most inventory is in the most common sizes, opposite ends of sizes get less inventory, i.e. kids and very large adults. Usually first come, first served so kids get stuck with too large BCDs, plus sized divers get stuck with wetsuits that are too restrictive.

Rental gear is often so very, very old and abused, i.e. full foot fins with torn foot pockets, BCDs with velcro that won't stay attached, don't even get me started on masks and regs.


So, if it was Dive 1 of Day 2, they likely reused a tank from the day before and knew the pressure. Or it was initial descent on Dive 2. Or they were on their "graduation" dive, which would also explain their nonchalance towards finding her. I've heard instructors on multiple instances say something to the effect of, "you're a certified diver now, if you die that's on you". On my OW, I was told to go "dive away" in Athens with 5' vis never having a single guided dive the entire weekend. Only 3 of us in the class opted to do a "fun" dive. 1 of them got to the houseboat at whatever depth, freaked out and bolted back to the surface. Diver 2 would have too, but that was my wife and she wasn't going to leave me alone.

It was Saturday morning so I assume it was Day 1. I was informed by someone on site that she had been found at 11:11 am that day. So if she was lost, found, and word made it to an unrelated student in another dive shop’s class who then told me at 11:11, I was thinking Day 1 Dive 1, or beginning of Dive 2.

 

[kammel78]

It was Saturday morning so I assume it was Day 1. I was informed by someone on site that she had been found at 11:11 am that day. So if she was lost, found, and word made it to an unrelated student in another dive shop’s class who then told me at 11:11, I was thinking Day 1 Dive 1, or beginning of Dive 2.

Day 1, then and likely Dive 1 going by the time. Unfortunately, allowing a student to start a training dive with 1050psi wouldn't surprise me. The nonchalance on losing a student during initial descent does shock me. All wild speculation, of course.

 

[cerich]

In what way is it a standards violation? Or do you just want an argument?

I gave examples of possible mitigations, I did not give recommendations. You may have missed the part where I said "additional supervision" when you were inventing the strawman of a divemaster doing everything while the instructor bumbles around blind. Possibly you also missed the part where I said "Can I...?" when you were getting on your soapbox. Or reducing student nmbers to the point where an instructor can see everything. But don't let reading get in the way of having a whine.

It sounds like you don't really understand risk assessments. An RA is not the same as a general operating procedure. An RA is worthless if it is treated as something you just get down off the shelf and randomly pick a response with no thought. It needs to be done each and every time a diving activity is planned or it is pointless. As such, you need to come up with a set of mitigations that can be justified every time. Alternatively you either accept or avoid the risk. This is very basic risk management done in every single industry that takes itself remotely seriously. But the recreational dive industry is not a serious industry, it's a minimum wage pyramid scheme with the added bonus of everyone at the top playing litigation dodgeball wth everyone at the bottom for extra excitement.

In the UK, all diving for reward, whether that is saturation diving offshore or teaching open water students, is governed by the Diving at Work Regulations. One of the foundations of DAWR is that a risk assessment must be done and recorded for every diving activity and environmental considerations are a mandatory part of that RA. There is an additional code of practice for recreational diving that explains how dive instructors can demonstrate that they have met their legal obligations under DAWR. Inshore, we generally have low visibility year round around most of the coast (at least most of the populated coast). Going by the latest figures from BSAC accident analysis, there is not one single fatality involving a trainee in low visibility. That would suggest to me that training divers in fairly ****** water isn't something to be clutching your pearls over if appropriate safe diving procedures are adopted. Bad visibility doesn't kill people, bad decision making does.

Nice long avoidance of the fact it will violate standards, even if what you suggested is in fact a common way to mitigate brisk on open water courses.

Of the major agencies, all have a requirement for the instructor to be in direct supervision except for some guided by a qualified assistant (AI/DM) when no skills are done at end end of certain dives. It's a standard that is commonly broken.

Having taught in conditions like you described in UK, I agree, it can be done. I also will affirm that many places teach OW in crap conditions, short CW training, use assistant but don't have direct supervision and students die.

BSAC, is..a different animal from the past in many ways (good ways mostly IMHO)

 

[HiddenDiver]

Day 1, then and likely Dive 1 going by the time. Unfortunately, allowing a student to start a training dive with 1050psi wouldn't surprise me. The nonchalance on losing a student during initial descent does shock me. All wild speculation, of course.

What your saying is that Scuba Toys allowing people to dive with 1050PSI is not an uncommon practice?
That's a bit odd being Day 1, Dive1. But yes, they did find the girl at 11:11am. They noticed she was missing well before 10:30AM because that's when they asked my group for help, and already at this point, we had emergency response already there and helicopter arrived shortly after.

 

[kammel78]

What your saying is that Scuba Toys allowing people to dive with 1050PSI is not an uncommon practice?
That's a bit odd being Day 1, Dive1. But yes, they did find the girl at 11:11am. They noticed she was missing well before 10:30AM because that's when they asked my group for help, and already at this point, we had emergency response already there and helicopter arrived shortly after.

No, that's not what I said, just to be clear. I know some of the divers/instructors out of that shop, but other than that can't speak with first hand knowledge about that shop's OW practices.

I can say, knowing the average instructor around here and classes I've witnessed first hand, that having a student (especially a smaller child with typically lower air consumption) start a dive with a 15' - 20' max depth, no swimming, and maybe 20 min dive time start a dive with 1050 psi because, the valve rolled off in the car on the way over, or the shop shortfilled, or they forgot a tank and had to borrow someone's half empty, and didn't notice until everyone was geared up and ready to get in the water - would not surprise me. The same way Linnea's instructor telling her she didn't need a drysuit inflation hose didn't surprise me. Time pressure - it's not just a factor in overhead diving, instructors succumb to it all the time.

On the other hand, can't count the times I've sat in the water during an overhead class, waiting on a student to fix (fill in the blank). Hell, I remember floating 20 min at Peacock 'cause my buddy imagined his cf backplate was making him too floaty (with double 104s) and insisted on swapping it out for his steel.

I've coined the term for the general mentality down here as the "good enough" mentality. "It's good enough til it ain't". That's the line Gareth talks about.

 

[GLOC_The Human Diver]

I've coined the term for the general mentality down here as the "good enough" mentality. "It's good enough til it ain't". That's the line Gareth talks about.

That term is spot on and is used in so many parts of our lives, especially when dealing with time pressures, incomplete knowledge of the situation (uncertainty), and some experience to deal with the situation.

It's called 'satisficing' in the academic literature.

And it's how we get through life on a daily basis. It's how Sully managed to ditch in the Hudson. It's also why, sometimes, things go really wrong because we've missed a critical step as we're distracted or we've got something else 'more' important to attend to.

The ability to cross-check within the team is why effective teamwork and mutual accountability are so important, but rarely taught in diving.

Unfortunately, the diving community sucks at sharing stories around near-misses. The outcomes get talked about, but the slips, lapses, mistakes, adaptations, and workarounds don't. These happen all the time, and provide brilliant, non-lethal learning opportunities. "What happens underwater stays underwater." - That is what my MSc thesis was about.

 

[texfox98]

That term is spot on and is used in so many parts of our lives, especially when dealing with time pressures, incomplete knowledge of the situation (uncertainty), and some experience to deal with the situation.

It's called 'satisficing' in the academic literature.

And it's how we get through life on a daily basis. It's how Sully managed to ditch in the Hudson. It's also why, sometimes, things go really wrong because we've missed a critical step as we're distracted or we've got something else 'more' important to attend to.

The ability to cross-check within the team is why effective teamwork and mutual accountability are so important, but rarely taught in diving.

Unfortunately, the diving community sucks at sharing stories around near-misses. The outcomes get talked about, but the slips, lapses, mistakes, adaptations, and workarounds don't. These happen all the time, and provide brilliant, non-lethal learning opportunities. "What happens underwater stays underwater." - That is what my MSc thesis was about.

Hey Gareth, so leaving aside the team component for a moment, I want to see if I understand. You’re saying that in normal life - school, work, etc., we operate on a “good enough” basis to get by - like, yes, double checking we have all lunches, school supplies, work supplies, reusable shopping bags for the grocery run, verifying all that is in the car would be great but in reality there is too much chaos to be consistent for most people. So if my kid forgets her math homework, it’s inconvenient but just normal life fallout. Not a life or death.

In life or death situations where there is a time constraint, like Sully, we have to also use the good enough thinking - there’s not going to be time to create a perfect plan, even if a perfect plan were possible, so we roll with what we’ve got in that moment.

In situations that seem routine but actually are life and deatg, there’s a tendency to fall back to that good enough mentality. There are time constraints, but the time constraints aren’t life or death - if we start the dive late or have to postpone it because we leveled up to a higher level of perfection in our checks and expectations around safe operating, it would be inconvenient and could have financial implications but no one is less safe because of it. But since we are used to operating in that good enough mentality, we take the chance of overlooking serious risks, that sometimes turn deadly.

And then back to the team part I guess, the solution to that last situation is to - change our thinking? Or to institute systems including team accountability to prevent it? Or maybe both? I’m wondering if that type of thinking is so ingrained it’s not practically possible to change it on a broad basis, and so instead we focus on systems, or if it’s both. Or if I am off base with the whole thing. It’s an interesting thought problem for me.

 

[GLOC_The Human Diver]

@texfox98, yes, you are pretty much there.

Most of the decisions we make are based on pattern-matching with previous experiences. If it looks close enough, we don't really pay much attention to the situation and 'make do'. This is why the attribution of 'loss of situation awareness' is a poor one when things go wrong, because we can't pay all of our attention at one thing all of the time. Like saying "An instructor is always to be aware of where their students are all the time." Our brains don't work that way. This blog explains that premise in more detail.

In terms of Sully and satisficing, often people think we go through logical decision-making choices when things start to go wrong. They think we sit there, identify the multiple options available, weigh up their benefits, and then choose the 'right one'. In reality, what happens is we identify the option that immediately 'satisfices' the situation and work on that. If that doesn't work, they choose the next best option. This means that sometimes we can get stuck in the wrong rabbit hole because we don't step out of the tunnel. To make the 'best decisions' we need experience. Sully said after his ditching "For the past 42 years I have been paying into the bank of experience, and on this particular day, I had enough to make a very large withdrawal." This blog helps understand this type of decision-making (along with some other models).

What you've done is brought out a brilliant point - the processes by which we make decisions are common - it is the context and outcome that changes and shifts our perspective of 'successful' or 'bad' outcomes (Outcome bias, hindsight bias, severity bias). Professor James Reason, the guy behind the Swiss Cheese Model, started looking into 'human error' when he put cat food into a teapot! He was working in the nuclear sector and recognised that if he could make a mix-up like this in a calm, controlled environment, what was to stop someone in a nuclear plant from doing something similar, but instead of cat food and tea, it would be a switch selection? His comment, "We can't change the human condition, but we can change the conditions in which humans work", was all about making it easier to do the right thing and harder to do the wrong thing.

I’m wondering if that type of thinking is so ingrained it’s not practically possible to change it on a broad basis, and so instead we focus on systems, or if it’s both.

This, in essence, is what the programmes from The Human Diver are about. They are based on Crew Resource Management (CRM) and Non-Technical Skills (NTS), the goal of which is to create a shared mental model in the team (a diving class is a team effort), and to create an environment where people can speak up and challenge without fear of social or professional retribution (psychological safety). There are literally hundreds of blogs and podcasts on The Human Diver site that cover these topics, and also different self-paced programmes from 30 minutes to 4.5 hours, and for you being in TX, there are also face-to-face Applied Skills classes run in Plano at Scuba Adventures. I am not a sponsor, so I am not going to put a direct link in here, but it won't take much of a search engine query or ChatGPT question to find out more.

If you want to know more, drop me a PM, or visit the contact page on The Human Diver site and send me a message.

Regards

Gareth
Founder/Director, The Human Diver

 

[texfox98]

@texfox98, yes, you are pretty much there.

Most of the decisions we make are based on pattern-matching with previous experiences. If it looks close enough, we don't really pay much attention to the situation and 'make do'. This is why the attribution of 'loss of situation awareness' is a poor one when things go wrong, because we can't pay all of our attention at one thing all of the time. Like saying "An instructor is always to be aware of where their students are all the time." Our brains don't work that way. This blog explains that premise in more detail.

In terms of Sully and satisficing, often people think we go through logical decision-making choices when things start to go wrong. They think we sit there, identify the multiple options available, weigh up their benefits, and then choose the 'right one'. In reality, what happens is we identify the option that immediately 'satisfices' the situation and work on that. If that doesn't work, they choose the next best option. This means that sometimes we can get stuck in the wrong rabbit hole because we don't step out of the tunnel. To make the 'best decisions' we need experience. Sully said after his ditching "For the past 42 years I have been paying into the bank of experience, and on this particular day, I had enough to make a very large withdrawal." This blog helps understand this type of decision-making (along with some other models).

What you've done is brought out a brilliant point - the processes by which we make decisions are common - it is the context and outcome that changes and shifts our perspective of 'successful' or 'bad' outcomes (Outcome bias, hindsight bias, severity bias). Professor James Reason, the guy behind the Swiss Cheese Model, started looking into 'human error' when he put cat food into a teapot! He was working in the nuclear sector and recognised that if he could make a mix-up like this in a calm, controlled environment, what was to stop someone in a nuclear plant from doing something similar, but instead of cat food and tea, it would be a switch selection? His comment, "We can't change the human condition, but we can change the conditions in which humans work", was all about making it easier to do the right thing and harder to do the wrong thing.



This, in essence, is what the programmes from The Human Diver are about. They are based on Crew Resource Management (CRM) and Non-Technical Skills (NTS), the goal of which is to create a shared mental model in the team (a diving class is a team effort), and to create an environment where people can speak up and challenge without fear of social or professional retribution (psychological safety). There are literally hundreds of blogs and podcasts on The Human Diver site that cover these topics, and also different self-paced programmes from 30 minutes to 4.5 hours, and for you being in TX, there are also face-to-face Applied Skills classes run in Plano at Scuba Adventures. I am not a sponsor, so I am not going to put a direct link in here, but it won't take much of a search engine query or ChatGPT question to find out more.

If you want to know more, drop me a PM, or visit the contact page on The Human Diver site and send me a message.

Regards

Gareth
Founder/Director, The Human Diver

That makes a lot of sense! I’ve noticed in my own behavior that fallback to patterns hundreds of times - your example with the cat food reminded me of the time, when my daughter was an infant, when I sealed a bag of breast milk, grabbed a marker to put the date on it, and without thinking labeled it with my last name, the date, and my badge number, as if it were a bag of evidence going in the evidence locker!

I’ll start working through some of the materials on the website and go from there! I just finished the YouTube if your presentation on Linnea Mills - some went over my head but I’m very interested, not just as a diver but also as a person. It aligns with a lot that I’ve seen in the workplace - corporate and government- and in how people just live from day to day. I’m curious about what the solutions look like and their potential to be adapted.

Thank you!