Two divers critical - Hawaii

[loosenit2]

That requires everyone to actual want that, which actually isn't the case. Agencies and insurance companies have to be willing to get rid of the bad apples and the instructor that was involved in this accident absolutely was a bad apple, he was reported way before this accident for a laundry list of bad instruction, lying, theft, and fraud. He was never going to participate in a just culture - except maybe to say all the right buzz words so he looked legit. Because if he actually was self aware enough to be a part, he would have quit teaching before this fatality even happened.

If this guy was a truck driver, he would have 2000 points on his (revoked) CDL, uninsurable, and un-hirable. And possibly in jail for stealing customer's cargo.

You seem to have read the first sentence of my post and not the rest of it. In order to create a culture of safety it is sometimes necessary to take litigation and punitive action off the table to get everyone talking in order to discover underlying causes of accidents. You jumped straight from culture of safety to fear of punitive action.

 

[rjack321]

You seem to have read the first sentence of my post and not the rest of it. In order to create a culture of safety it is sometimes necessary to take litigation and punitive action off the table to get everyone talking in order to discover underlying causes of accidents. You jumped straight from culture of safety to fear of punitive action.

Perhaps
But been around long enough to realize there aren't actually any punitive damages. Just internet rage followed by insurance settlements a few years later. There was a fatality up in Vancouver recently, AOW class (during a pandemic but hey gotta keep the students churning through!), "deep" (ie 100ft target) dive on a deep wall with the bottom way beyond air diving depths (180+ft), new diver, terrible visibility, buddied with another newish diver. Forgot how many students but too many for the instructor to watch them all in the available vis. Diver lost control of his buoyancy due to a disconnected power inflator, task loaded both him and his buddy on fixing it until he was overcome by suit compression and/or Co2 at 150ft+. Died with gas in his tank and weighs still on him. Instructor was back out teaching the next weekend. Sometime in 2024-ish padi will settle with the family to avoid anymore waves.

Sorry just culture is a farce without actual justice for criminal negligence. Sure you can say what if Brian had done X, Y, or Z. But the instructor in this case should have been booted years before, so this class with him never should have happened in the first place. That would have been the unicorn punitive action that doesn't ever seem to happen with the high rolling, big talking, incompetent instructors.

 

[John the Pom]

A typical O/C diver is usually very positive on the surface, so if there is an incident and they lose consciousness or have some physical problem they stay afloat. With CCR accidents at the surface, it often seems that, as soon as a significant quantity of water enters the breathing loop, they lose buoyancy and sink. Is this right?

 

[rjack321]

A typical O/C diver is usually very positive on the surface, so if there is an incident and they lose consciousness or have some physical problem they stay afloat. With CCR accidents at the surface, it often seems that, as soon as a significant quantity of water enters the breathing loop, they lose buoyancy and sink. Is this right?

Yes the loop plus scrubber(s) are at least 4L and sometimes as many as 8L of air space. If you flood that, they are going to be really negative and sink. Even just 4L of air is about 9lbs of buoyancy.

 

[Brad_Horn]

A typical O/C diver is usually very positive on the surface, so if there is an incident and they lose consciousness or have some physical problem they stay afloat. With CCR accidents at the surface, it often seems that, as soon as a significant quantity of water enters the breathing loop, they lose buoyancy and sink. Is this right?

Yes, which is one of the reasons why the rEvo in this case came from the manufacturer fitted with a Drager gag strap to retain the DSV in the divers mouth. If fitted, that prevents this issue as it seals the loop to prevent both it and the diver drowning, even if unconscious...
This is one of the CE certification requirements for EN14143 marking on any rebreather.
Unfortunately in this case I understand that manufacturer supported instructor was known to remove the gag straps from units he taught on to remove this safety factor.... based on the evidence that they weren't present on either this fatality nor others attributed to the same instructor nor any units he's pictured with.

The alternative to prevent issues like this is an auto-bailout feature that triggers a bail out valve to close if the mouthpiece is removed from the dives mouth.
As found on OSELs ALVBOV and triggered by either the necklace pulling against the divers neck or the spring loaded trigger being pushed. https://www.facebook.com/pg/OpenSafetyEquipment/photos/?tab=album&album_id=151310394898469

 

[clownfishsydney]

Excellent documentary, probably the best breakdown of an accident I have seen. Should never have led to this outcome, so many small problems all aligning. Too rushed to become a deep rebreather diver is the main one in my view, not enough experience in open circuit would also appear to be a factor (less than three years).

Very brave of Ashley to be involved in this.

 

[Saniflush]

I will respond first from my training and experiences in personnel management outside of scuba. I was trained in various forms of what people call "creating a culture of continuous improvement." It assumes that participants want to improve and will thrive in a nonjudgmental, coaching environment focused on making everyone all they possibly can be. I have been part of such an environment at times, and I thought it worked great.

Looking back on my career, though, it only works great in an environment in which that ideal attitude is spread throughout the group. It runs into trouble when you have what some people call a "bad apple." There really are people who are not interested in doing the best they can. There really are people with no interest in improving. There really are people who want only to game the system for their own personal benefit. As I type, the images of such people I knew both as colleagues and subordinates are flashing through my mind. Unfortunately many management systems are set up solely to deal with such types, and the truly virtuous majority suffers. On the other hand, those evil individuals absolutely must be dealt with effectively, but they rarely are, especially when they find themselves in the friendly, coaching environment I just described. They can destroy such an environment. The old adage of one bad apple spoiling the whole barrel has a strong foundation in truth.

This is spot on! I run a manufacturing facility where we do custom metal fabrication and finishing. We have the best continuous improvement program that I have seen in our industry and most others but it has been a very slow grind to get there with my 100 or so employees (about 10 years) I attribute it to a few things...

First, I hire the best people I can. Usually these come from recommendations of current good employees. The current employees do not want someone here who will not pull their weight or buy into the culture. The continuous improvement culture starts first and foremost with a firm safety culture. A subset of this is I try like hell to keep the good people. We are tied to commercial construction so there is no shortage of other industries that have a lot better pay scales who try to hire my employees. 75% of my employees have been here 5 years or more and about 50% have been here 10 years or more.

Secondly, I have never fired ANYONE for making a mistake. During a new employees orientation I tell each one of them this. Most do not believe me but it's true and they find it out after they are here a while. If they are afraid to make a mistake for fear of being fired then they won't do anything and I rather have someone trying to do something and get it wrong then sitting on their ass paralyzed by fear of making a mistake. Because we work in custom metal fabrication mistakes happen daily for all matter of reasons and as long as they are learning from the mistake I can live with it but I make a point of drilling down on why a mistake happened so we all know and hopefully can get better. Some systems call this driving out the fear and I think that is a fair summation of it.

Thirdly, I am a no nonsense type of a person and am not afraid to lay the law down to someone who is a problem child. This ranges from an informal counseling to walking someone out of the door and everything in between. Employees see this and know that I have their back when it comes to quality and continuous improvement. Managers/bosses have to have the intestinal fortitude to make the hard call and handle what needs to be handled in a timely manner. In my experience a continuous improvement system or mentality is only attainable and sustainable through constant vigilance over the system. As a boss/manager you cannot allow a problem to fester to the point where other people who are doing their jobs well are affected by the "bad apple's" poor decisions or laziness.

I have seen other organizations try to implement similar systems and fail horribly and by my estimation each failure is attributable to one or a combination of these things.

Rant over and sorry for the thoughts that I'm sure are all over the place...I have not finished my first pot of coffee yet.

 

[Jcp2]

I think another thing that influences the probability that a culture of safety can be implemented is the size of the organization as compared to the size of the pool of potential organizational members. It’s way easier to have a team of high performers when you can choose only all star candidates, but when there are more spots than stars, selectivity goes down. Not imagine a company employing thousands of people, maybe even the largest employer in an area. Then the expectations for performance and safety and diligence and productivity all have to be decreased because of the mediocre talent pool. Maybe you can focus on a couple, but at the expense of the others.

 

[Jack Hammer]

Great program! I hope it will help others and encourage people to ask questions before a class.

Interesting to note one of the instructors backed out of teaching the course due to the students not having the required hours on the unit.

 

[rjack321]

I think another thing that influences the probability that a culture of safety can be implemented is the size of the organization as compared to the size of the pool of potential organizational members. It’s way easier to have a team of high performers when you can choose only all star candidates, but when there are more spots than stars, selectivity goes down. Not imagine a company employing thousands of people, maybe even the largest employer in an area. Then the expectations for performance and safety and diligence and productivity all have to be decreased because of the mediocre talent pool. Maybe you can focus on a couple, but at the expense of the others.

At least in the scuba industry there's no cap on the number of instructors at all. Churning as many as possible through IDCs seems to be the goal with many agencies and training centers. Which is pretty much the exact opposite of selecting high performers who "buy into" continuous improvement.