Training Scuba Ranch TX Diving Accident
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GLOC_The Human Diver
Contributor
I got mentioned in this thread, but not tagged, so I didn't know about this until yesterday. I had to create a new account as the email address I had registered is no longer accessible.
Firstly, I don’t have enough details, so I won't comment on any specific aspects relating to the event itself. I will make reference to points made re: human factors and how errors/failures occur. There are multiple links to resources within the post as there is a limit to what can be covered in a post.
“However, they're promoting the Human Factor class. I'm not saying that's right or wrong, but I feel that if they are going to promote the Human Factor class based off this incident, then I think it's also a good idea to talk about the "human factor" that may have prevented this incident to begin with.”
The posts made weren’t about promoting the class per se, I provided information about trauma (FB post) and the need to make sense of a tragic event (blog). Human factors applies to many aspects of diving, including the social and commercial pressures to undertake dives. This blog describes what four key 'types' of human factors are. What you have described below as the “human factor” is just one type.
“With vis at 5ft, should you be taking a full class with you? If we were to apply the "Human Factor" in this situation, the instructor and/or the dive masters should have called off the dive.”
Hindsight is a powerful bias, as are severity and outcome biases. When I am asked to look at an event, I ask ‘what is normal?’ Accidents happen as deviations from 'normal', not necessarily deviations from the rules. Rules and 'normal' can be the same, but often they are not. What was different on this day and wasn't spotted prior to the event by those involved?
How many other people were diving that weekend?
Were the temperature and visibility conditions normal?
That doesn’t mean it is ‘right’ or ‘wrong’, but it shows that there is always more to it.
Safety is about maximising margins while being cognisant of financial and resource constraints – there is always a trade-off, which is called 'risk management'. When we erode margins, we make it harder to fail safely. We rarely fall off a cliff of failure, and that is why we have many things go right, and a few things go wrong, some of them catastrophically. The diving industry is marketed as a safe, sexy, and accessible sport for all. It is internally-regulated (badly IMHO) with commercial viability as one of the driving factors for standards. For anyone involved in the safety sector, the quality management processes within the diving industry are very poor, but that is because if they were more stringent, the costs would go up for this hobby business that takes place in an inherently hazardous environment.
The Linnea Mills case wasn’t just one thing; it was many, starting at the diving industry level which allows self-certification, very few dives are required to be an instructor, and almost zero practical requalifications. Brian Bugge’s fatality wasn’t a simple thing either; there were many factors that contributed and converged on the day. We like simple, linear answers. Fatalities and serious injuries are rarely simple if you look at how they emerge.
When a fatality occurs, it is easy to see where the edge of the safety margin was. Our biggest bang for buck is when our toes are on the 'failure line', but we don't know where that is until we step over it. For normal diving operations, the measure of safety is the absence of a fatality or serious injury, and if we don’t have a fatality or serious injury, we must have been safe. This might appear illogical, but this is how our 'fast' brains work.
“I also believe that we should be talking about the situation. I understand the family is heartbroken. But for the betterment of the community, we need to learn from this. This is a very real event that happened very recently. Additionally, more classes with new students will be entering the same water with same conditions this coming weekend. Staying quiet doesn't help anyone. What if we lose other new OW students this weekend? How many times have to lost in the past in similar conditions?”
Talk about ‘what’? I made a statement at Rebreather Forum 4.0 two years ago, and I stand by it. There are not enough dead divers to make a difference. Change happens because of a major and/or sustained emotional trigger. 200+ divers dying each year doesn't hit that threshold. That isn't to say each fatality is not a tragedy for those involved, but at a system level, it is not very many deaths. And the way events are 'examined' in diving, the focus is on 'the last to touch it', and very rarely do people look 'up and out' to find answers. That's because there isn't a learning structure present in diving.
The blog I wrote on Sunday talks about searching for meaning following a tragic loss, and if learning doesn’t appear to be happening, then blame starts to surface. The factors (social, technical, cultural, and environmental) that contribute to a fatality are known. Think about the following:
There are many individual, small factors that in themselves won’t make a difference, but when you stack them up, they create a major issue.
We like to reduce events to a simple, linear cause-and-effect, and that is a massively flawed approach. There are no root causes in a complex situation (and any event where you have people is complex). If you think there is a root cause for a failure, think about the following. If you go back far enough, success and failure start in the same time and space. As such, tell me what the root cause of success is, because there are way more successes than failures. If there isn't a root cause for success, why would there be one for failure?
It is a tragic situation for all involved. It is one of the reasons I posted the Restorative Just Culture checklist: who has been hurt? What do they need? Whose obligation is it to meet that need? Much of the help can come from the community looking inwards to yourself and doing two things:
Chris (@cerich ) is right, the training programmes that The Human Diver has developed do not exactly align with the sports diving industry and the way it is managed, but I don’t mind working hard to shift the culture towards one of learning and away from one where blame (a normal human reaction) is changed for learning. You've got to start somewhere, and rather than reinventing the wheel, I am taking established processes, tools, and techniques from high-risk industries and repackaging them for the diving sector. The real problem I have is the lack of levers to pull. These ideas run counter to commercial interests within the diving industry, and the erosion of margins is inevitable when you rely on personal integrity in a highly competitive, self-regulated industry. If you consider human factors and system safety, the system is setting instructors and divers up to fail... humans are fallible. Create systems that allow them to fail safely.
If you want to get FREE resources, then visit the blog, the podcast, or the YouTube channel. You can find paid-for resources if you look. I am not going to link to them.
Regards
Gareth
Founder, The Human Diver.
Firstly, I don’t have enough details, so I won't comment on any specific aspects relating to the event itself. I will make reference to points made re: human factors and how errors/failures occur. There are multiple links to resources within the post as there is a limit to what can be covered in a post.
“However, they're promoting the Human Factor class. I'm not saying that's right or wrong, but I feel that if they are going to promote the Human Factor class based off this incident, then I think it's also a good idea to talk about the "human factor" that may have prevented this incident to begin with.”
The posts made weren’t about promoting the class per se, I provided information about trauma (FB post) and the need to make sense of a tragic event (blog). Human factors applies to many aspects of diving, including the social and commercial pressures to undertake dives. This blog describes what four key 'types' of human factors are. What you have described below as the “human factor” is just one type.
“With vis at 5ft, should you be taking a full class with you? If we were to apply the "Human Factor" in this situation, the instructor and/or the dive masters should have called off the dive.”
Hindsight is a powerful bias, as are severity and outcome biases. When I am asked to look at an event, I ask ‘what is normal?’ Accidents happen as deviations from 'normal', not necessarily deviations from the rules. Rules and 'normal' can be the same, but often they are not. What was different on this day and wasn't spotted prior to the event by those involved?
How many other people were diving that weekend?
Were the temperature and visibility conditions normal?
That doesn’t mean it is ‘right’ or ‘wrong’, but it shows that there is always more to it.
Safety is about maximising margins while being cognisant of financial and resource constraints – there is always a trade-off, which is called 'risk management'. When we erode margins, we make it harder to fail safely. We rarely fall off a cliff of failure, and that is why we have many things go right, and a few things go wrong, some of them catastrophically. The diving industry is marketed as a safe, sexy, and accessible sport for all. It is internally-regulated (badly IMHO) with commercial viability as one of the driving factors for standards. For anyone involved in the safety sector, the quality management processes within the diving industry are very poor, but that is because if they were more stringent, the costs would go up for this hobby business that takes place in an inherently hazardous environment.
The Linnea Mills case wasn’t just one thing; it was many, starting at the diving industry level which allows self-certification, very few dives are required to be an instructor, and almost zero practical requalifications. Brian Bugge’s fatality wasn’t a simple thing either; there were many factors that contributed and converged on the day. We like simple, linear answers. Fatalities and serious injuries are rarely simple if you look at how they emerge.
When a fatality occurs, it is easy to see where the edge of the safety margin was. Our biggest bang for buck is when our toes are on the 'failure line', but we don't know where that is until we step over it. For normal diving operations, the measure of safety is the absence of a fatality or serious injury, and if we don’t have a fatality or serious injury, we must have been safe. This might appear illogical, but this is how our 'fast' brains work.
“I also believe that we should be talking about the situation. I understand the family is heartbroken. But for the betterment of the community, we need to learn from this. This is a very real event that happened very recently. Additionally, more classes with new students will be entering the same water with same conditions this coming weekend. Staying quiet doesn't help anyone. What if we lose other new OW students this weekend? How many times have to lost in the past in similar conditions?”
Talk about ‘what’? I made a statement at Rebreather Forum 4.0 two years ago, and I stand by it. There are not enough dead divers to make a difference. Change happens because of a major and/or sustained emotional trigger. 200+ divers dying each year doesn't hit that threshold. That isn't to say each fatality is not a tragedy for those involved, but at a system level, it is not very many deaths. And the way events are 'examined' in diving, the focus is on 'the last to touch it', and very rarely do people look 'up and out' to find answers. That's because there isn't a learning structure present in diving.
The blog I wrote on Sunday talks about searching for meaning following a tragic loss, and if learning doesn’t appear to be happening, then blame starts to surface. The factors (social, technical, cultural, and environmental) that contribute to a fatality are known. Think about the following:
- How many divers maintain the currencies/competencies needed?
- How many are fit enough to effect a rescue and conduct CPR?
- How many analyse their gas on EVERY dive?
- How many divers follow their ascent profile exactly?
- How many divers get an annual medical to screen for issues?
- How many divers skip checklists?
- How many divers enter the water with equipment that isn't 100% serviceable?
There are many individual, small factors that in themselves won’t make a difference, but when you stack them up, they create a major issue.
We like to reduce events to a simple, linear cause-and-effect, and that is a massively flawed approach. There are no root causes in a complex situation (and any event where you have people is complex). If you think there is a root cause for a failure, think about the following. If you go back far enough, success and failure start in the same time and space. As such, tell me what the root cause of success is, because there are way more successes than failures. If there isn't a root cause for success, why would there be one for failure?
It is a tragic situation for all involved. It is one of the reasons I posted the Restorative Just Culture checklist: who has been hurt? What do they need? Whose obligation is it to meet that need? Much of the help can come from the community looking inwards to yourself and doing two things:
- Move from asking why and who (the answers serve very little purpose when it comes to learning), to ‘how did it make sense for this to happen?’ What are the conditions that exist (technical, social, cultural, environmental) that lead to such events? I see the name of the school mentioned. To me, that is almost irrelevant to wider organisational learning, what quality management systems are in place to manage ALL schools/centres, and are they effective? How do you know? Note, it isn't because of an absence of an adverse event...
- Asking ‘what do I do that is similar to this and what can I change to reduce the likelihood of a similar event occurring, and WHEN it does, what can I do to fail safely?’
Chris (@cerich ) is right, the training programmes that The Human Diver has developed do not exactly align with the sports diving industry and the way it is managed, but I don’t mind working hard to shift the culture towards one of learning and away from one where blame (a normal human reaction) is changed for learning. You've got to start somewhere, and rather than reinventing the wheel, I am taking established processes, tools, and techniques from high-risk industries and repackaging them for the diving sector. The real problem I have is the lack of levers to pull. These ideas run counter to commercial interests within the diving industry, and the erosion of margins is inevitable when you rely on personal integrity in a highly competitive, self-regulated industry. If you consider human factors and system safety, the system is setting instructors and divers up to fail... humans are fallible. Create systems that allow them to fail safely.
If you want to get FREE resources, then visit the blog, the podcast, or the YouTube channel. You can find paid-for resources if you look. I am not going to link to them.
Regards
Gareth
Founder, The Human Diver.
Gareth, appreciate the well thought response and your insight.
I would like to comment on a few of your points, for the little my $0.02 is worth.
You mentioned the name of the shop is irrelevant in driving system wide learning, which is partly true - as in the case of Gull Divers knowing the name uncovers additional breakdowns in quality management tied to patterns of deviance - but more importantly systemic change (top down) is only one lever to drive change. In just about any commercial industry, transparency is a major driver of self-regulation. If the general public has the impression your product kills them, falls out of the sky, explodes in their pockets, etc. your company is at a great financial risk and you have a financial incentive to protect that reputation. If a dive shop has an accident and that accident affects their reputation and further, their business, regardless of fault, that is the risk they incur in that business. If they were at fault, then good, the system is self-correcting to an extent. If they were not at fault, transparency is their only weapon. Either way, I am not concerned with protecting a business that I have no financial interest in from the risk it knowingly entered into. If some people have to get hurt or die to find where the "failure line is", then I have no problem with some businesses also having a negative impact in pursuing that line.
NOT talking about who, what, where, and why only protects those with a financial stake. Of course, we're a niche industry with hardly a fraction of the information spread of a commercial airline, so you could make a valid argument of whether or not that information actually achieves anything, but IMO the principle is still right regardless of the outcome. I also acknowledge that I'm being a bit unfair, because I'm focusing more on post-accident bottom up mechanisms whereas your lens is directed more at preventative measure on a top down, systemic level.
The other point that I think is important is viewing accidents through the lens of "what is normal?" and any thereafter deviance from said "normal". Through this perspective, you're spot on, however the question at stake here is not deviance from normal but a reevaluation and level setting of what we're defining as "normal", specifically in this case environmental conditions and class standards for OW classes. Also factor in what we know now about the deteriorating quality of our fresh water sources from pollution, runoff, etc (i.e. Project Baseline, KUR, WKPP, FSA, etc) and these same OW sites that have been normalized for so long may have possibly deteriorated to point of unsuitability. Coupled with this we have no set agreement, and are admittedly bad at evaluating compounding risk. Vis is easy, but to your point on Linnea - it's a number of factors. How do you add Vis + relatively shallow thermoclines + relative instructor experience + number of students + bottom composisiton + number of divers that day + conditions that are worse the 2nd day? I have no clue. But it is an important question to ask and talk about.
IMO, all dialogue is good dialogue as long as we're asking questions and not just finger pointing. The commenter that your quoted resulted in a great response that provided you an opportunity to educate and give perspective that others may not have ever heard were it not for their post. Granted sometimes the dialogue goes too far, but using your "failure line" analogy, we don't necessarily know where that line is regarding incident analysis until we step over it.
Always appreciateive to hear your perspective, Gareth.
Travis
GLOC_The Human Diver
Contributor
"If the general public has the impression your product kills them, falls out of the sky, explodes in their pockets, etc. your company is at a great financial risk and you have a financial incentive to protect that reputation. If a dive shop has an accident and that accident affects their reputation and further, their business, regardless of fault, that is the risk they incur in that business. If they were at fault, then good, the system is self-correcting to an extent. If they were not at fault, transparency is their only weapon. Either way, I am not concerned with protecting a business that I have no financial interest in from the risk it knowingly entered into. If some people have to get hurt or die to find where the "failure line is", then I have no problem with some businesses also having a negative impact in pursuing that line."
Herein lies the issue. You only find out that there is an 'issue' with an organisation WHEN there is an adverse event. That event could be down to issues outside of their control. I've heard of boat captains being accused of being 'unsafe' when there are medical-related fatalities onboard. Is that a captain's issue? Or something happening at depth? Is that a captain's issue? The weaponisation of systemic failures at the individual level is an easy 'out' because it hides the wider problems. Identifying the dive shop will show that A failure occurred. If multiple minor failures have happened and not been detected, then that is a failure of the quality management system. If multiple minor failures have occurred across the industry without a failure, that is a failure of the wider system for learning.
Your point about the multiple factors is spot on. We don't make quantitative risk assessment during our diving, because the data is so poor. We use emotional arguments, biases and hueristics, and when things go wrong (near-miss) we often say "I won't do that again" but what does 'that' mean. The decision in the moment or the wider contextual issues? The way that sports diving 'manages' risk is to push the liability to the instructor/dive centre or student through waivers and 'accepting liability' without giving them to tools to understand how and why we make the decisions we do - commercial pressures make it harder to speak up and challenge the status quo. These are difficult and messy things to talk about. The industry, in general, aims at a relatively low denominator and wants to make things simple and linear. Compliance is easy to measure (e.g., slates for tasks). Talking about how to determine if something is 'safe' (or 'unsafe') when everyone else is diving in the same conditions is much harder.
To your final point, we will never know where the failure line is until we step over it. That's the point. We don't have a crystal ball. When we do, we have to have the conditions to talk about the adaptations, workarounds, and the local ingenuity that is present in everyday diving instruction and fun diving and 'bad things' haven't happened. If we just focus on that event and that team, then we miss so much learning.
Unfortunately, human nature is such that we need failures to put the spotlight in place. For the Linnea Mills case, drysuit training was a known issue, but it was an 'acceptable' risk. For the two fatal diving accident enquiries I've led for the UK MOD and the NZDF, latent issues were present, and if the fatalities hadn't happened, I wouldn't have been there. "We accept the risk".
Keep the conversation focused on the conditions and context, not on the individuals.
Regards
Gareth
Herein lies the issue. You only find out that there is an 'issue' with an organisation WHEN there is an adverse event. That event could be down to issues outside of their control. I've heard of boat captains being accused of being 'unsafe' when there are medical-related fatalities onboard. Is that a captain's issue? Or something happening at depth? Is that a captain's issue? The weaponisation of systemic failures at the individual level is an easy 'out' because it hides the wider problems. Identifying the dive shop will show that A failure occurred. If multiple minor failures have happened and not been detected, then that is a failure of the quality management system. If multiple minor failures have occurred across the industry without a failure, that is a failure of the wider system for learning.
Your point about the multiple factors is spot on. We don't make quantitative risk assessment during our diving, because the data is so poor. We use emotional arguments, biases and hueristics, and when things go wrong (near-miss) we often say "I won't do that again" but what does 'that' mean. The decision in the moment or the wider contextual issues? The way that sports diving 'manages' risk is to push the liability to the instructor/dive centre or student through waivers and 'accepting liability' without giving them to tools to understand how and why we make the decisions we do - commercial pressures make it harder to speak up and challenge the status quo. These are difficult and messy things to talk about. The industry, in general, aims at a relatively low denominator and wants to make things simple and linear. Compliance is easy to measure (e.g., slates for tasks). Talking about how to determine if something is 'safe' (or 'unsafe') when everyone else is diving in the same conditions is much harder.
To your final point, we will never know where the failure line is until we step over it. That's the point. We don't have a crystal ball. When we do, we have to have the conditions to talk about the adaptations, workarounds, and the local ingenuity that is present in everyday diving instruction and fun diving and 'bad things' haven't happened. If we just focus on that event and that team, then we miss so much learning.
Unfortunately, human nature is such that we need failures to put the spotlight in place. For the Linnea Mills case, drysuit training was a known issue, but it was an 'acceptable' risk. For the two fatal diving accident enquiries I've led for the UK MOD and the NZDF, latent issues were present, and if the fatalities hadn't happened, I wouldn't have been there. "We accept the risk".
Keep the conversation focused on the conditions and context, not on the individuals.
Regards
Gareth
I will first describe an incident that has nothing to do with this case and then use it to make what I hope is a point related to the current discussion.
Years ago, I met a divemaster in Mexico who told me of this local incident. An instructor had a class of 8 students, and the shop used a DM candidate as an assistant. They dropped down in crystal clear water, and the instructor arranged students in a circle to perform skills. One of the students had a problem, and the instructor took the student to the surface, leaving the students with the DMC. Then another student had a problem, and the DMC attended to it, finishing just as the instructor returned. They returned to their positions, learning then that another student had died and was lying in the sand with the regulator out.
The fact that leaving the students with a DMC was a standards violation is not the point. The point is that no one noticed a student having a problem and dying while they were in close proximity in crystal clear water.
I myself conducted many OW training dives in low visibility conditions in Colorado. I never had an incident. I realized after awhile that it was not because I was so very good at my job. A lot of it came down to sheer luck. Scuba really is pretty darn safe, so whatever causes a diver to have a safety incident is very rare, but it can happen. When it happens in poor visibility, no one will know until it is too late.
The classes I led in Colorado, the classes offered in poor visibility around the entire world, are inherently unsafe, and we do not have the high fatality rate that Gareth mentions because of the fact that scuba diving really is in itself pretty safe. The difference between a dive shop with a stellar record and a dive shop with a higher failure rate may be just a matter of luck.
Years ago, I met a divemaster in Mexico who told me of this local incident. An instructor had a class of 8 students, and the shop used a DM candidate as an assistant. They dropped down in crystal clear water, and the instructor arranged students in a circle to perform skills. One of the students had a problem, and the instructor took the student to the surface, leaving the students with the DMC. Then another student had a problem, and the DMC attended to it, finishing just as the instructor returned. They returned to their positions, learning then that another student had died and was lying in the sand with the regulator out.
The fact that leaving the students with a DMC was a standards violation is not the point. The point is that no one noticed a student having a problem and dying while they were in close proximity in crystal clear water.
I myself conducted many OW training dives in low visibility conditions in Colorado. I never had an incident. I realized after awhile that it was not because I was so very good at my job. A lot of it came down to sheer luck. Scuba really is pretty darn safe, so whatever causes a diver to have a safety incident is very rare, but it can happen. When it happens in poor visibility, no one will know until it is too late.
The classes I led in Colorado, the classes offered in poor visibility around the entire world, are inherently unsafe, and we do not have the high fatality rate that Gareth mentions because of the fact that scuba diving really is in itself pretty safe. The difference between a dive shop with a stellar record and a dive shop with a higher failure rate may be just a matter of luck.
Steelyeyes
Contributor
I'm not an instructor although I helped one with classes a few times. I just can't see how teaching basic scuba in low viz is a good idea. Talk about complicating factors. Someone should have had the wisdom to call the dive before anyone got wet. I'd hate to be the adult that made the choices that day.
GLOC_The Human Diver
Contributor
This is the point I made above. If people knew with 100% certainty that things would go wrong, they would call the dive. However, when the context and conditions are normalised (even though they are marginal), plus you've got commercial pressures and social pressures to complete the training, the decision isn't so easy and clear-cut. That is hindsight bias in action.
If the fatality didn't happen, would you still "hate to be the adult that made the choices that day?"
This is outcome and severity bias in play.
All three biases are normal human behaviour.
lizardland
Registered
Bad visibility on its own isn't necessarily a problem. Not taking it into consideration and letting other factors compound it is a very big problem. Scotland, where I am from, has consistently bad visibility in the waters around its two biggest cities and diver training still goes ahead, both professionally and in club training. Reduce numbers, increase supervision, choose a place with favourable topography, etc. Making no adaptation and treating it like any other dive is going to lead to something bad happening. Sadly, a lot of instructors got their training in conditions far more benign than where they intend to teach, they don't gain any experience in low visibility, they have no local diving experience and if they are working for a shop or school they will very often be too tight to cut student numbers or provide a suitable divemaster (despite it being a legal obligation here to have someone else acting as cover and for a risk assessment to be done for every dive).
Steelyeyes
Contributor
In my opinion visibility low enough that you can't see every student makes it advanced conditions beyond the scope of basic scuba. I know the instructor had to make a living and probably had other factors motivating them to do the course but stretching the bounds of safety is not wise.
We have had fatalities in classes here in Puget Sound that were in part due to very low visibility. I don't think it's too much to ask to learn from other people's mistakes instead of repeating them and hoping for a better outcome.
I had a career operating a fairly large high voltage power system for a local utility. In order to hopefully eliminate accidents and fatalities our crew had the pleasure of multiple human error prevention classes. I guess I'm a bit picky about normalization of deviance.
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