Training Scuba Ranch TX Diving Accident

[HiddenDiver]

Going off on a tangent here, but one thing to point out is that humans go about day to day as a normal routine. We get so desensitized to repetitive behaviors that we sometimes overlook things.
But many times, when we talk about human factors, that's when mistakes are made. Largely, those mistakes are small and non-threatening in nature. Most mistakes can be undone.

Part of risk management is to assess the outcome and determine the frequency of task being performed, difficulty of the task being performed, and importance of the task being performed. In the training world, we call this the DIF analysis. But that is a whole another topic.

To put this into perspective, a person would generally just dial phone numbers without thinking too much. It's just a routine task. But what if we knew that if I miss a number or two, it would accidentally dial my ex...or worse... my mother-in-law? I would take the time to dial the correct number not to accidentally dial the wrong person. Risk is too great!

In diving, especially when there is higher level of risk, we tend to add barriers to ensure that mistakes are not made. Rebreather divers use checklists to ensure we perform all steps, but it also slows us down and gives us extra time to think about what we're doing.

When teaching a class of open water divers, I feel that we can utilize these same tools. We can slow down and concentrate on what we're doing. Taking a minute or two to assess the class and make sure that everything is squared away would mitigate errors.

I understand that scuba diving is generally a very forgiving sport. However, when catastrophic events happen, it does lead to death.

 

[GLOC_The Human Diver]

Part of risk management is to assess the outcome and determine the frequency of task being performed, difficulty of the task being performed, and importance of the task being performed.

This is an important aspect, aligned with what I've said above about how we make decisions.

The frequency of adverse (or near-miss) events is really hard to determine because stories are suppressed, for a whole raft of reasons. Recency bias means that if we haven't heard about something going on, it doesn't get added to our mental models as being relevant 'to me'. This is why the narrative changes when something 'bad' happens, despite the same 'conditions' being present on 'successful' dives.

The questions we ask after an adverse event are the same questions we should be asking before an event. We don't need a fatal outcome to put the spotlight on 'normal' human behaviours and the conditions we are diving/instructing within.

Regards

Gareth

 

[HiddenDiver]

The questions we ask after an adverse event are the same questions we should be asking before an event. We don't need a fatal outcome to put the spotlight on 'normal' human behaviours and the conditions we are diving/instructing within.

This is the key point. We need to learn from mistakes that we made, no matter how small it is.

 

[GLOC_The Human Diver]

It might appear as semantics but it is an important distinction.

We will continue to make slips (execution error), lapses (forgot something) and mistakes (doing the wrong thing, thinking it's the right thing), we can't prevent that. What we can do is look at the conditions around the event so we make it easier to do the right thing, and not the wrong thing.

- Financial conditions (what instructors/DMs get paid, what consumers are willing to pay)
- Environmental conditions (vis, temp, current...). Both topside and under.
- Competitive and anti-learning cultures (Not related to this event, but received yesterday. "Concerns about the shop's Course Director sweeping near-misses under the carpet.")
- Training systems geared towards compliance and passing the IDC to generate a high number of certifications, which supposedly means they are a good dive centre.
- Quality management that is based on happy sheets, not performance-based assessments on a regular basis.

If we know these conditions exist, what are 'you' as a dive instructor or dive centre manager/owner going to do differently? Just because you haven't had something reported (or gone wrong), it doesn't mean you are 'safe'. You may have been lucky (something already covered earlier in this thread).

And the list goes on.

Regards

Gareth

 

[kammel78]

When teaching a class of open water divers, I feel that we can utilize these same tools. We can slow down and concentrate on what we're doing. Taking a minute or two to assess the class and make sure that everything is squared away would mitigate errors.

The crux of this problem, though, is dive shops have no financial interest in self-regulating above the current "good enough" state and for instructors you're relying on individual will to be better than "good enough". This is the point Gareth and I disagree on the most. In the absence of financial incentive (carrot), and assuming no meaningful agency change, I believe reputation risk (stick) is the only lever we have to effect any measurable outcomes.

Instructors and dive shops that do want to better, will be better. Those that don't, won't and will continue to kill people. Those that do want to do better will only benefit from transparency of these incidents.

The scuba industry is faced with an issue of poor personal judgement and lack of enforcement. The universal example of the success of checklists is only effective if there's some form of checklist enforcement. The enforcing agencies in scuba diving for the most part, have no desire to do such, so we rely more and more on personal judgement.

So now we're back to changing human behavior to make people want to do better. And to do that we can use the classic choices of positive reinforcement, negative reinforcement, or punishment. Pick your poison.

 

[GLOC_The Human Diver]

I agree with what you’ve written. @kammel78

Punishment only works if it is ‘fair and independent’ - that isn’t present in the diving sector for a whole raft of reasons.

Behaviour can be changed when you change the language in the training system and across the community. However, there is no organisational interest in that given that ‘compliance’ is the name of the game in a financially competitive environment, where there is a race to the bottom and the safety metric (dead divers) isn’t really an organisational focus.

Regards

Gareth

 

[kammel78]

I agree with what you’ve written. @kammel78

Punishment only works if it is ‘fair and independent’ - that isn’t present in the diving sector for a whole raft of reasons.

Behaviour can be changed when you change the language in the training system and across the community. However, there is no organisational interest in that given that ‘compliance’ is the name of the game in a financially competitive environment, where there is a race to the bottom and the safety metric (dead divers) isn’t really an organisational focus.

Retards

Gareth

Somewhat related...in most countries with a criminal justice system in place, it's mostly understood that punishment should strive for fairness and independence, however there's an acceptable level of risk to those innocent in order to maintain the greater benefit to society.

caveat - there are so many holes we can poke in the criminal system, my only point is an agreement that punishment should strive to be, and have mechanisms in place to be as "fair and independent" as possible.

Travis

 

[HiddenDiver]

The crux of this problem, though, is dive shops have no financial interest in self-regulating above the current "good enough" state and for instructors you're relying on individual will to be better than "good enough". This is the point Gareth and I disagree on the most. In the absence of financial incentive (carrot), and assuming no meaningful agency change, I believe reputation risk (stick) is the only lever we have to effect any measurable outcomes.

Instructors and dive shops that do want to better, will be better. Those that don't, won't and will continue to kill people. Those that do want to do better will only benefit from transparency of these incidents.

I am on the same boat with you here. I agree with Gareth on many things, but similar to your point, I disagree with him here.

Good example is the airline industry. I understand the need for regulations to ensure safety, but when planes fall out of the sky, plane manufacture and airline company both face reputational damage that results in financial impact.

Take the most recent instance for example. We have dive shops that uphold the highest of standards. We have Scuba Adventures promoting Human Factor and GUE training to better diver education and safety... but on the other hand, we have Scuba Toys that (allegedly) didn't uphold the highest of standards beyond the minimum. After the accident, Scuba Toys is taken off Scuba Ranch's list of shops on their website, probably will have difficulty training there, their calendar of training is wiped clean, and it wouldn't surprise me if the shop closes its doors as legal troubles starts mounting up. It is in the best interest for shops to do the right thing.

 

[GLOC_The Human Diver]

"It is in the best interest for shops to do the right thing." - I don't disagree. Integrity is doing the right thing, especially when no one is watching.

The point is that the latent conditions already existed before the fatality. You don't need the fatality to trigger the learning (change). As I said above, punishment is acceptable to the community when there is fairness, and that often involves independence. A Just Culture does exist in this sense, i.e., justice, but where is the independence in diving? How is it 'fair' that a dive shop/operation that breaks standards and doesn't have a fatality is not punished for non-adherence to standards, yet the same failed 'processes' can lead to profits as long as a trigger event doesn't happen? The quality management system in the diving industry sucks because it doesn't make use of the feedback systems that can help, including reporting. It's why I wrote this article last weekend.

Drawing to your point about reputational damage:

"I understand the need for regulations to ensure safety, but when planes fall out of the sky, plane manufacture and airline company both face reputational damage that results in financial impact."

Ironically, you could say that the major training organisations are like Boeing. They have enough capital to ride out the storm, continue to milk the system, and transfer risk to the lowest levels possible.

Reputational risk management is no different in diving to other domains: Volkswagen, Wells Fargo, Boeing... those who get harmed (physically/emotionally) are not those in senior positions. The money is already in the bank. That's why the arguments about reputational damage make very little difference to safety in the diving sector. That is, unless there is a major uproar, and you could say that the liveaboard operations in the Red Sea are now facing that - it took lots of lives to be lost and the involvement of national government bodies like the UK Coastguard to make a difference. Did the massive loss of life on the MV Conception change much in terms of US-based boat operations... I would be very confident that nearly all the other operators in the area were behaving the same way prior to the night of 2 September 2019. Was that vessel 'unlucky' compared to others?

This is a system's problem, and so a systems approach is needed.

Regards

Gareth

 

[sea_ledford]

I heard that Scuba Toys have tendencies to hire freelance instructors to teach their classes. Not saying that hiring freelance instructors are bad. But I would feel that having in-house instructors doing most or all the instructions would carry different weight. But that's just me. However, I do know that most tech instructors are freelance.

Just to touch on the freelance, or independent contractors, aspect:
This is pretty normal across the industry in my experience. It can be for either intentional and regulation abiding methods, or it can be for essentially tax evasion.

Shops will hire independent instructors so they don't have to pay any benefits or employment taxes on them. The instructors are self employed and are responsible for all their own taxes. In that situation, the independent instructor could technically sub contract out the work to another instructor and the shop couldn't do anything about it. The shop also couldn't require the instructor work in the shop on the sales floor, for example, or even dictate schedules. Of course that ISN'T how most independent instructors are treated. They are simply treated like employees and told who, when and where to teach.

On the other hand, any CCR instructors have to be independent because there is no OSHA approved CCR. If there is an employer/employee relationship, the employer has to follow OSHA regulations (even if they have never heard of OSHA). Don't have to follow that guideline for contractors because they aren't employees.