Training Scuba Ranch TX Diving Accident

[lizardland]

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.

I don't disagree. My point is that one single factor isn't necessarily creating a negative outcome. It's a compounding of many factors. You can teach in low visibility if you are willing to make adaptations. Those adaptations are usually costly in some way (1:1 student ratio, added supervisory personnel, going to a less convenient site that doesn't have the potential to lose a student in, going further afield to find better vis, taking more time/more dives with students, etc). Low visibility is not the problem, not adapting to low visibility is the problem. At the end of the day, some sort of risk assessment has to inform how the diving is done and whether anyone gets in the water. Too often what actually happens is that the decision making is done based on "I need to get this finished so I get paid" or "I know what I'm doing, I'm an instructor" or "I don't want to let down this student" or "the divemaster can look after everyone I can't see".

I take your point about normalisation of deviance (I also work in a job where things go bang) but equally for a big part of the world low vis is the normal. If we start making a wide-ranging ban on low vis training then everyone is going to end up training in an environment that is the polar opposite to what their local conditions are. That just seems perverse to me and as much of a failing as ploughing ahead with no thought to conditions would be.

 

[divezonescuba]

I did not want to mention the diveshop associated with the incident in my OP as it was not verifiable at the time.

But, since someone else has now identified the diveshop, I would be curious as to what certification agency was involved.

I looked up the diveshop and I did not see significant mention of a certification agency identified with their training programs at the open water level. However, there is mention of NAUI at professional level courses.

 

[boulderjohn]

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.

If something were to go wrong in a dive on which you are assisting and there is a subsequent lawsuit, you would not have the liability protection that comes with professional status. I am a retired instructor, and I will not assist a class.

 

[divezonescuba]

Just as bad, if an instructor allows a certified tag along to be in an open water group, then the instructor is also legally liable for the tag along.

 

[HiddenDiver]

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.

Gareth,

I wasn't speaking of you when I mentioned the promotion of Human Factor classes. I get that you own the program, but I was more irked by Milton promoting the class on the back of this tragic event on a local dive page that he admins while preventing any and all comments on that page that relates to the event. You can't even ask what happened. But surely, the speculation runs wild.

I get that the family is grieving and people involved are traumatized. But if I was a parent about to send my children into those waters the next day or the next week and I had no idea what was going on, wouldn't it make sense to fill me in so I can assess the risk?

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?

Monday morning quarterbacking definitely gives us the bias. Being in the airline industry, this is definitely talked about. 100 planes that almost fell out of the sky carries less weight than the 1 plane that does. However, in the airline industry, we critique each of those events and draft up Lesson Learned. We distribute them as fast as we can so that the learnings can be had on most recent events. Part of the training program is finding recent events that relates to the training topics so that it is more relatable. This includes industry events and events outside of our industry.

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.

There are no single event that caused this. This is the whole "Swiss-cheese" model. All the holes aligned and casualty happened. And just because we were safe yesterday doesn't mean we will be safe today. And it is true that there are more safe events than un-safe events. But it doesn't mean that we should continue doing our business the way we kept doing it.

Lastly, I'd like to end with this reminder. I wasn't taking digs on you or the Human Factor classes. I think they are great and should be the industry standard. What bothered me was someone else, probably not related to you, that was promoting the class on the back the tragic event, at the height of the trauma, while preventing others from even mentioning it on the Facebook page that he admins. He said it was to show respect to the family involved....but seems like the respect fell short when a class could be promoted.
Human Factor is a great class and I learned a lot from it...but I think there's a bit of a mixed messaging here.

 

[GLOC_The Human Diver]

Thanks for the clarification and the support @HiddenDiver.

I totally get the aviation approach, as you know, that is also my background. As I have highlighted in a couple of posts, the diving industry doesn't have the learning culture or the tools/techniques to understand the factors (technical, social, non-technical, or environmental) that allow such learning to happen (from understanding, to analysing, to dissemination, to change). There are many systemic issues that prevent real learning from adverse events.

Even the most recent NSS-CDS report that was published about a rebreather fatality (hypercapnia, underwater seizure) said something along the lines that the diver forgot the spacer and this allowed the CO2 to breakthrough. The diver didn't follow a checklist. And yet missed a whole bunch of factors around conditions and context, including the design of the rebreather that doesn't have a forcing function that prevents the unit from being used if this spacer isn't fitted. There are a couple of blogs on the THD site about taking HF approaches to adverse events but we don't get the information needed to make a report to even the same level as an aviation preliminary report.

In terms of Milton's post, I believe this is because I sent him the RJC checklist and the link to the work of Dr Laura Walton from Fit to Dive on how to deal with trauma following an accident. Posting the information would have been done with the best intentions.

Relating to the parent question, a fair point. At the same time, I doubt logic would make a difference. It is no different to people being 'illogical' when they moved to driving cars following the attacks of 9/11 because flying was 'unsafe' or people taking much longer car journeys in 2002 when there was the sniper team firing from a modified Chevvy in Washington DC. The alternative mode was less safe, but in their minds it was safer.

Regards

Gareth

 

[wgw04024]

Not to change the subject, but this is a great example of why after my OW class, I realized it would of been a much better experience if I had done the check outs all in Florida or in another more friendly water condition environment.

Everyone always says...do your check outs locally even if it's ****. Nobody takes flying lessons and starts out in on their first flights in fog and at night.

 

[Steelyeyes]

If something were to go wrong in a dive on which you are assisting and there is a subsequent lawsuit, you would not have the liability protection that comes with professional status. I am a retired instructor, and I will not assist a class.

It was outside of the USA and the overly litigious society we have here. I still have a significant liability insurance coverage for other reasons though.

 

[kammel78]

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?

It's not at all, but I see risk going both ways with scuba diving. Risks to divers as well as risk to those who wish to make a living profiting off of scuba diving. It's not fair if a Captain catches blame for an accident they didn't directly contribute to. It's also not fair for a student to die because of an inept instructor. But that risk of being blamed for a health related issue may motivate (some) Captains to have a stricter policy on who they allow to dive. Commercially operated dive sites such as SR may want to start requiring more documentation from "instructors" during check in or institute a dirt cheap survey monkey to random paying customer asking to anonymously rate their class/instructor.

I don't think any of those changes would happen organically if businesses didn't have some risk of no fault loss to reputation. In a niche, unregulated industry this is just about our only tool.

 

[DOBY]

Not to change the subject, but this is a great example of why after my OW class, I realized it would of been a much better experience if I had done the check outs all in Florida or in another more friendly water condition environment.

Everyone always says...do your check outs locally even if it's ****. Nobody takes flying lessons and starts out in on their first flights in fog and at night.

I totally agree that such low visibility conditions shouldn’t be used for initial training or discover scuba classes. Just because thre’s nothing in the standards that totally prevents it, doesn’t mean it’s OK

But it only fine to learn in “more friendly conditions” if you just plan on only diving warm clear Caribbean conditions. Most competent instructors recommend getting certified in conditions you will normally dive. Here in the Great Lakes that’s cold & sometimes dark conditions. Which means low student to instructor ratios (like two students per instructor and no more than 4 with a 1 or 2 certified assistant.