Student lost - Seattle, Washington

[DAJ]

I would prefer to learn from another’s experience through facts that support a learning point so that others that are engaged in a similar situation or activity can apply the lessons learned to avoid a similar conclusion. I would argue that it is difficult to learn an appropriate response through speculation and conjecture as the learning point you are trying to stress about a specific scenario may not have even occurred and your reactions to correct the discrepancy are grounded on incomplete information.

Granted, many are going to become involved in the mental gymnastics of trying to figure out how this type of event developed and what others should do but in the end, it’s just one of many opinions and at this stage, one has just as much validity as another because the only one that knows for sure what happened is the one person that can no longer tell us. Every possible scenario for this incident can be further branched out in to many more and only your imagination can determine when this would end.

You respond to an exact incident such as this and you wonder:
1. Did the diver have a medical condition that resulted in this death
2. Did the diver just panic from the water conditions that caused this
3. Did the diver lose contact with others and then panic
4. Did the regulators (first or second stage) fail in some way that attributed to this
5. Did the cylinder have enough air - not the first time a near empty tank was used
6. Did the mixture in the cylinder cause this
7. Did a mask failure cause them to panic
8. Did the victim have any mental issues or suicide ideation
9. Did others on the dive have any reason to harm this victim
10. Did this diver have a history of other issues while diving
11. Did another student exacerbate this outcome
12. Did a dive instructor play a part in this outcome

These are some of the tangents these types of things can develop into given enough time but in just looking at this list, where is the learning point from the perspective of speculation and conjecture? Sure, we can take the position of “if this is what happened, we should do this to prevent a future occurrence” but the lesson needs to ring true.

 

[NothingClever]

I would prefer to learn from another’s experience through facts that support a learning point so that others that are engaged in a similar situation or activity can apply the lessons learned to avoid a similar conclusion. I would argue that it is difficult to learn an appropriate response through speculation and conjecture as the learning point you are trying to stress about a specific scenario may not have even occurred and your reactions to correct the discrepancy are grounded on incomplete information.

Granted, many are going to become involved in the mental gymnastics of trying to figure out how this type of event developed and what others should do but in the end, it’s just one of many opinions and at this stage, one has just as much validity as another because the only one that knows for sure what happened is the one person that can no longer tell us. Every possible scenario for this incident can be further branched out in to many more and only your imagination can determine when this would end.

You respond to an exact incident such as this and you wonder:
1. Did the diver have a medical condition that resulted in this death
2. Did the diver just panic from the water conditions that caused this
3. Did the diver lose contact with others and then panic
4. Did the regulators (first or second stage) fail in some way that attributed to this
5. Did the cylinder have enough air - not the first time a near empty tank was used
6. Did the mixture in the cylinder cause this
7. Did a mask failure cause them to panic
8. Did the victim have any mental issues or suicide ideation
9. Did others on the dive have any reason to harm this victim
10. Did this diver have a history of other issues while diving
11. Did another student exacerbate this outcome
12. Did a dive instructor play a part in this outcome

These are some of the tangents these types of things can develop into given enough time but in just looking at this list, where is the learning point from the perspective of speculation and conjecture? Sure, we can take the position of “if this is what happened, we should do this to prevent a future occurrence” but the lesson needs to ring true.

This. This is the direction of discussion and moderation we should be headed towards.

Instead of gossiping like a bunch of sorority girls, we should focus on educational webinars each quarter (based on DAN and other professional organizations) that draw out the key lessons from incidents.

@DAJ is a PSD. If we’re quick to discard his inputs, it seems we’re more inclined to entertainment rather than really improving our activity.

I expect better from ScubaBoard’s leadership and members.

 

[wetb4igetinthewater]

The only information we will receive is the autopsy report. If I'm not mistaken, when the OW student was lost at Cive 1 five years ago, the autopsy report was drowning. No other information was given that could be used to mitigate such future events.

Hence we are left with speculation. Placing blame on individuals as is often done doesn't seem to be working. A more productive approach is looking at the system in which the instructors were operating. At least this is what I learned from Gareth Lock's Human Factors workshop. And that's what I've attempted to do in this thread.

 

[yle]

You respond to an exact incident such as this and you wonder:
2. Did the diver just panic from the water conditions that caused this
3. Did the diver lose contact with others and then panic
7. Did a mask failure cause them to panic
12. Did a dive instructor play a part in this outcome

Unfortunately, night dives are easily the most stressful of the common AOW dives. I typically encourage my students to do deep, nav, S&R, wreck and night for their AOW course. The nav is some work, but in shallow water during the day. S&R is the same, typically the second dive after nav. The wreck and deep dives are fun and exciting, we take it nice and slow.

If there's one dive that's going to make a student's brain flip, it'll be the night dive. I've never had a problem, but I've always been aware that all it could take is a partial mask flood, not being able to see an SPG, or momentary spatial disorientation in the darkness to flip a student into panic mode. The student could otherwise be a perfectly capable and comfortable diver (which can lure the instructor toward complacency), but night dives are just different.

 

[chillyinCanada]

Unfortunately, night dives are easily the most stressful of the common AOW dives. I typically encourage my students to do deep, nav, S&R, wreck and night for their AOW course. The nav is some work, but in shallow water during the day. S&R is the same, typically the second dive after nav. The wreck and deep dives are fun and exciting, we take it nice and slow.

If there's one dive that's going to make a student's brain flip, it'll be the night dive. I've never had a problem, but I've always been aware that all it could take is a partial mask flood, not being able to see an SPG, or momentary spatial disorientation in the darkness to flip a student into panic mode. The student could otherwise be a perfectly capable and comfortable diver (which can lure the instructor toward complacency), but night dives are just different.

I'll never ever forget my first night dive which was indeed part of AOW. My first stage became tangled in fishing line.

 

[BRT]

For some reason I'm never so calm as on night dives. I just zone out.

 

[Bob DBF]

I would prefer to learn from another’s experience

So would I. I find it much less stressful, and terrifying, than the lessons I have learned from my own experience.

The only information we will receive is the autopsy report. If I'm not mistaken, when the OW student was lost at Cive 1 five years ago, the autopsy report was drowning. No other information was given that could be used to mitigate such future events.

Sounds like you got the coroners cause of death rather than the autopsy report, which would give more information.

The student could otherwise be a perfectly capable and comfortable diver (which can lure the instructor toward complacency), but night dives are just different.

To borrow a phrase from Mike Tyson, “Everyone has a plan until they get punched in the mouth.” Anyone can be a perfectly capable diver until something goes wrong, night dives are a perfect place for all manner of things to go wrong, especially when not mentally prepared.

 

[RainPilot]

This.

I just can’t wrap my brain around why we as a virtual community don’t adopt this mature, prudent outlook rather than the speculation and conjecture ditch we invariably slide into.

We go through this every couple of years on the Board. My personal approach (member hat on not staff):

There are two kinds of conjecture. One is based on trying to figure out what DID happen, the other is figuring out what COULD have happened. The first is a waste of time unless you have a professional interest (law enforcement, attorneys etc on actual case) and the other is a very useful safety tool.

For example, there is ZERO evidence around this actual case, but the known facts lead to some possibilities, and each of those possibilities can lead to some safety changes even if they had nothing to do with the specific incident. For example, in this case, I see the following amongst a hundred other things:

Why wasn't her light seen by the recovery team? Could be a few things.

1. No light at all for them to find. Possible causes and thoughts on future avoidance:
   1. Battery life long enough for dive, but died while she was drowned on the bottom - maybe I need to look at how much burn time I have remaining before diving with this in mind. Before on a night dive, if my estimated battery life was just enough for the dive plus a bit, I'd be fine because I would have my backup to deploy if it did go wrong in the last few minutes. Also, I can't deploy a backup if I am unconscious so thats something to think about.
   2. She was overweighted, had a medical problem and sank to bottom ending up lying on her light in a silty bottom - maybe I need to rethink my opinion on tank beacon lights, and be more thoughtful about having a light both sides of the body of my students.

Note, there's a lot more stuff to unpack around the few things we know and many possible causes of the incident, but here's the important part, for me:

I cannot know the cause, and knowing the actual cause, for me, has zero safety implication. It might make my ego feel good (I don't do that so my students are safe!) or it might evoke schadenfreude over some other entity I don't like but there is NO benefit to my students or my profession knowing the actual cause.

What these threads do is evoke discussion and thinking on what it MIGHT have been, and while I may not be guilty of any of the type of misdeeds that happened on the ACTUAL case, I can guarantee that I am guilty of at least one of the things it COULD have been.

 

[DAJ]

I cannot know the cause, and knowing the actual cause, for me, has zero safety implication. It might make my ego feel good (I don't do that so my students are safe!) or it might evoke schadenfreude over some other entity I don't like but there is NO benefit to my students or my profession knowing the actual cause.

This has to be one of the most unprofessional and shortsighted comments that I have read in some time from a "professional" in the diving industry. You hold the position that knowing the actual facts of a diving fatality will provide you, your students, and the rest of the diving community no benefit and yet you discuss implementing increased policies, procedures, and further financial burden on your students based on what you think may have contributed to the incident instead of making corrections to your current procedures grounded on factual information.

It doesn't matter if the investigation shows the mix in the tank was bad or that her first stage regulator failed, you would rather focus on adding more lights to a diver so they can be seen better at night. It's one thing to dive in areas with great visibility and take advantage of the conditions but if the visibility is poor, you can be lit up like a Christmas tree and unless the searcher is right on top of you, they are not going to see you. Even focusing on a possible dive light at night is not the best practice for approaching this type of recovery. You focus on the victim and if you happen to notice a light that's fine but you approach the dive not considering a light. If the recovery diver is focusing on the assumption that "there should be a light visible", they may swim right by the victim and not see them because they are focused on finding light and not the victim.

Truly knowing the actual cause of a dive accident and deciding if appropriate changes should be considered is vital and extremely important. If the information is there, use it to make educated decisions. Not every dive fatality may be seen as a teaching moment or drive specific changes in training and policy to correct the issue. If a diver dies from a brain aneurism that is not attributed to diving, most will see that as just an unfortunate incident and move on. Others might stress the importance of a healthy lifestyle or reminding you to make sure you have periodic physical exams but for the most part, it will not impact the diving community or cause additional concerns for the average diver.

Just throwing corrective measures at the wall to see what sticks is not helping make you or your divers any safer and you are inflating your own ego as you are making assumptions on what might have happened and then implementing changes that you think are required based on your opinion. Maybe she lost her mask, better make the students carry and extra. Maybe the first stage quit, better make sure all students have an independent first/second stage setup. Maybe she had a light but it was not bright enough, better make sure all student dive with 21 watt can lights. If only she could have communicated that she was in distress, better make sure all students wear an Aga mask with comms. Again, knowing the facts and exactly why this incident occurred would eliminate all these knee-jerk reactions to address potential problems that are only imagined and not factual. All of this still only applies if anyone even decides to make a change. Most incidents, short of manufacture defects that cause injury/death, will remain uneventful and we will see similar outcomes again. It is difficult to force change on those that have never experienced the issue so you must be careful of what you determine to be the new requirement to fix an issue that many may feel is not wanted or required.

 

[mtoyama]

We go through this every couple of years on the Board. My personal approach (member hat on not staff):

There are two kinds of conjecture. One is based on trying to figure out what DID happen, the other is figuring out what COULD have happened. The first is a waste of time unless you have a professional interest (law enforcement, attorneys etc on actual case) and the other is a very useful safety tool.

...

I cannot know the cause, and knowing the actual cause, for me, has zero safety implication. It might make my ego feel good (I don't do that so my students are safe!) or it might evoke schadenfreude over some other entity I don't like but there is NO benefit to my students or my profession knowing the actual cause.

What these threads do is evoke discussion and thinking on what it MIGHT have been, and while I may not be guilty of any of the type of misdeeds that happened on the ACTUAL case, I can guarantee that I am guilty of at least one of the things it COULD have been.

I had to re-read this a few times. Maybe I'm misunderstanding, because this is pretty much the opposite of what should be done.

NHTSA and NTSB, for example, meticulously investigate and analyze incidents in order to provide recommendations on changes based on the actual causes of the incidents.

Prescribing change based on imaginative speculation may lead you to overfitting your reaction to a fictional narrative, resulting in a false sense of security.

You are permitted to imagine possible scenarios based on speculation, and proactively attempt to implement solutions to those scenarios. But you should not pretend that your solution will address the actual cause of the incident, which you apparently don't care about.