...is something we never hear, but the concept that many divers actively or consciously choose to make decisions that will end in their demise appears to be rife.
"How could they be so stupid?"
"It was obvious that this would end in disaster?"
"Why didn't they just ditch their weights?"
"Didn't they remember their training?"
Below is the start of the full article from the The Diver Medic magazine. The magazine is free to download but has advertisers and sponsors, hence I have only provided the first part.
==============
"We cannot improve if we don’t learn. We cannot learn if we do not understand."
“The divers were instructed by the DM (dive master) to swim away from shore and then they were taken
away down current and then spent the next 7 hours fighting for their survival in 25-foot high waves
before being picked up some nine miles away...”
“How stupid could they be? It is obvious that they should have ignored the DM’s instructions and swam
to shore. That’s what I would have done”.
away down current and then spent the next 7 hours fighting for their survival in 25-foot high waves
before being picked up some nine miles away...”
“How stupid could they be? It is obvious that they should have ignored the DM’s instructions and swam
to shore. That’s what I would have done”.
“The instructor had a double cell failure in the rebreather which meant that the voting logic gave them
erroneous information in terms do of the pO2 (partial pressure of oxygen) within the breathing loop.
They carried on their dive despite numerous warnings provided by the controller that there was an
issue. Unfortunately, the voting logic meant that the solenoid was instructed to fire and the diver suffer
an oxygen toxicity seizure and drowned. Two of the three cells were approximately 40 months old,
more than three times the recommended age and well outside the recommended limits...”
“It’s obvious that he should have aborted dive when he had the warning. How stupid could he be? I’d
never make that mistake”.
erroneous information in terms do of the pO2 (partial pressure of oxygen) within the breathing loop.
They carried on their dive despite numerous warnings provided by the controller that there was an
issue. Unfortunately, the voting logic meant that the solenoid was instructed to fire and the diver suffer
an oxygen toxicity seizure and drowned. Two of the three cells were approximately 40 months old,
more than three times the recommended age and well outside the recommended limits...”
“It’s obvious that he should have aborted dive when he had the warning. How stupid could he be? I’d
never make that mistake”.
These relate to two real adverse events. In the first no-one died, but in the second the instructor
unfortunately perished despite being recovered from depth by his students who were taking an entry-level
(Mod 1) closed circuit rebreather class. The incidents themselves are almost irrelevant to the main theme
of this article. The reason? This article is going to focus on the way the diving community often makes
negative comments which does nothing to improve learning. Often we hear negative and aggressive
comments following incidents. Commentators are judging what happened without a full understanding of
the situation. Instead, we need to encourage a culture of being able to talk about the mistakes we make,
and more importantly, why it made sense to us to behave in the manner we did. Without this dialogue, we
are not going to be able to prevent future adverse events because we need the story, not just the statistics
of the number of people who die or get injured during scuba diving or apnea. It is impossible to teach
everything in a course, therefore, we need to learn by proxy. Learn from your mistakes. Better still: learn
from someone else’s.
Rest of the article
===========
Within the diving community there is a real issue with talking about failure in a constructive manner. Mathew Syed's book 'Black Box Thinking' has some excellent quotes covering a number of domains. If you think diving is bad when it comes to talking about failure, look at healthcare.
"It turns out that many of the errors committed in hospitals (and in other areas of life) have particular trajectories, subtle but predictable patterns: what accident investigators call ‘signatures’. With open reporting and honest evaluation, these errors could be spotted and reforms put in place to stop them from happening again, as happens in aviation. But, all too often, they aren’t...When our professionalism is threatened, we are liable to put up defences. We don’t want to think of ourselves as incompetent or inept. We don’t want our credibility to be undermined in the eyes of our colleagues...Society, as a whole, has a deeply contradictory attitude to failure. Even as we find excuses for our own failings, we are quick to blame others who mess up... It is partly because we are so willing to blame others for their mistakes that we are so keen to conceal our own. We anticipate, with remarkable clarity, how people will react, how they will point the finger, how little time they will take to put themselves in the tough, high-pressure situation in which the error occurred. The net effect is simple: it obliterates openness and spawns cover-ups. It destroys the vital information we need in order to learn...It is probably worth stating here that nobody wants to fail. We all want to succeed, whether we are entrepreneurs, sportsmen, politicians, scientists or parents. But at a collective level, at the level of systemic complexity, success can only happen when we admit our mistakes, learn from them, and create a climate where it is, in a certain sense, ‘safe’ to fail."
So when we finish a dive and it didn't go to plan, look at why that was the case. Was the plan flawed? Was the execution flawed? What reason was the execution flawed? Distraction? Lack of skills? Lack of communication?
Looking at the positive side, if it didn't go to plan, it might have exceeded expectations and look to understand why this was the case and develop those ideas further.
When we read about an incident or accident, don't immediately jump to the conclusion that they were being stupid, reckless or violating the rules of diving. Take the time to learn why it made sense to those at the time. People don't normally get up in the morning and decide "Today is a good day to die."
Errors are normal. Accidents are normal. They are normally the cause of predictable actions or inactions. The difficulty is determining when they will happen...
====================
Footnote:
The Human Factors Academy provides two classes to improve human performance and reduce the likelihood of human error of occurring. The online class provides a comprehensive grounding of Human Factors giving you the basic skills need to improve human performance and reduce error, whereas the classroom-based class is very comprehensive and intense with plenty of opportunity to learn from failure and error, and providing an opportunity to be reflective on behaviours and performance.
Online micro-class (9 modules of approximately 15 mins each) details are here. What have you got to lose? 15 mins a day to improve your personal and team performance? Human Factors Skills in Diving Online Mini-Course
Upcoming classroom-based course dates are here Training Course Dates
More information on Human Factors Skills in Diving classes can be found at www.humanfactors.academy
I will be presenting two sessions at DEMA on 17 & 18 Nov on Human Factors in Diving and how personal and team performance can be improved. Come and find me and have a chat if you are interested in this subject and would like more information.
