Virginian diver dead at 190 feet - Roaring River State Park, Missouri

[crofrog]

What have we learned from the roaring river accident or Gus's incident? Is there anything specific?
I'd be genuinely interested in hearing this.
Has anyone drawn some lesson from this?

Based on what we know of the incidents, it reinforces the following:

• Standardized and appropriate project gasses
• Standardized equipment configurations inside a team
• Robust pre-dive checks
• Team diving / team seperation protocols
• Gas that isn't breathable at depth should have the valves closed, or not be brought to depth in a cave.
• CCR checklist design, should include verifying dil pp02

All those controls provide overlapping protections against the risk of a fatality, and all of them have a non-zero cost to implement monetarily and from a time standpoint.

 

[DOBY]

…. during a mod1 class

Not to side-track the thread even further. But if I remember correctly, Brian Bugge’s accident/death occur during a CCR MOD II normoxic Trimix course. It might have even been a MOD III hypoxic Trimix course - not sure. But it wasn’t a MOD I CCR course. Even so, it certainly didn’t excuse the Instructor’s poor decisions

p.s. just started the first HF Diver course. And a lot of what I am learning very much applies to this accident and certainly to the Roaring River Spring accidents. IMHO

 

[PirateFoxy]

Nobody insisting on finding a single cause. In some case it's muddying the waters to talk about how some student felt and trying to somehow relate that to the instructors conduct. Also alot of stuff that people call 'hindsight' these days is not hindsight. Trying to push one model onto everthing doens't work all that great.


Have you used a ccr? Says not certified below your name.

It's not muddying the waters - the point is how the students felt meant they were not comfortable doing things like asking questions, pushing back on the instructor's timeline, saying "I'm just not feeling this dive today" etc. If they had felt able to do so then it's unlikely there would have been a diver getting in the water without having completed his checklist properly and been checked by a buddy, as they would not have been pushing ahead with the dive when some or all of them were not in a mental state to follow the correct procedures and protocols for safety. It's much harder to get in the water without remembering to turn on your air supply if you've gone through your 'pre-flight' checklist properly and been properly checked by a buddy, that's why people have checklists and buddy check procedures.

And nice selective quoting - I literally went on to say that if they were NOT able to assert themselves to thumb a dive, then that is also relevant as you can then not use procedures that rely on individual divers thumbing a dive if they don't feel like it's going to go well. In the case of a class, that would put more responsibility on the instructor to be assessing how students are doing mentally before the dive and be willing to thumb the dive before anyone gets wet if their assessment is that someone's head isn't in the game.

From reading other incident reports, there seems to be a wide variety of opinion on how much it's reasonable for an instructor to rely on students to thumb the dive - everyone seems to agree that with total newbies the instructor should expect to do everything, but there's a fair number of people who'll argue that once someone has OW certification, they can be relied upon to be responsible for themselves no matter what. If an instructor is operating on this mindset - that a qualified and experienced OW diver can be trusted to thumb a dive - but the reality is that in a class environment even experienced divers will hesitate and defer to the instructor contrary to how they are personally feeling, then that is a major safety issue that needs to be considered. This would potentially also apply in situations like the one in this thread, where psychologically a diver may be placing the team lead or other more 'senior' divers on the team in the mental role of 'instructor' in terms of who determines when to thumb a drive, or where a diver may feel hesitant to 'ruin' the plan by thumbing the dive and leaving the team with a role unfilled.

You simply can't limit opportunities for disastrous mistakes without understanding fully how those mistakes happen - which includes how individuals in the scenario are feeling and how that may be influencing their behavior and choices.

 

[berndo]

Based on what we know of the incidents, it reinforces the following:

• Standardized and appropriate project gasses
• Standardized equipment configurations inside a team
• Robust pre-dive checks
• Team diving / team seperation protocols
• Gas that isn't breathable at depth should have the valves closed, or not be brought to depth in a cave.
• CCR checklist design, should include verifying dil pp02

All those controls provide overlapping protections against the risk of a fatality, and all of them have a non-zero cost to implement monetarily and from a time standpoint.

I agree with this. Having said that, I wouldn't call it something new learned. I meant 'lesson' as in, is there somehitng new here. I reckon that some things in that group were considered normal or OK, that are generally considered safey violations in cave diving.

When you watch Gus's report of his incident, he doesn't acknowledge the issue. When someone asked about it on fb, a team member basically supported Gus's take.
Their surly were more issues and contributing circumstances, but IMHO it's essential that you really hammer down on the major issues.
That's my issue with the HF approach. I a bit too scatter-shot. The big issues need to be pointed out clearly and we more often than not know what they are.
With many accidents it's like 'oh, here we go again'. People should know what not to do when they have taken training and read books/reports. They just ignore it, over and over and over again. I don't know how to fix it, especially when people won't acknowlege the big issues to begin with.

 

[berndo]

It's much harder to get in the water without remembering to turn on your air supply if you've gone through your 'pre-flight' checklist properly and been properly checked by a buddy, that's why people have checklists and buddy check procedures.

Ok, so since you're avoiding my question, I'm going with the assumption you're actually not certified or in OW class. How do you make all these claims and assumption? I really think in order to talk about this and to form some kind of opinion you kinda need to know how a rebreather works and what it's like to be a dive student or instructor on some level.

As I said, the students in a class might be stressed, nervous, 'don't feel empowered', or whatever, that's normal. Students make mistakes, that is to be expected. That's why you have an instructor, so you don't kill yourself when you make a mistake.

 

[crofrog]

That's my issue with the HF approach. I a bit too scatter-shot. The big issues need to be pointed out clearly and we more often than not know what they are.
With many accidents it's like 'oh, here we go again'. People should know what not to do when they have taken training and read books/reports. They just ignore it, over and over and over again. I don't know how to fix it, especially when people won't acknowlege the big issues to begin with.

"Primary goals of human factors engineering are to reduce human error, increase productivity and system availability, and enhance safety, health and comfort with a specific focus on the interaction between the human and equipment.[1]"

The goal of HF is literally to solve the issue you're talking about. It's not a single big issue it's a handful of little issues that eventually lead to an incident.

In aviation, there is a term called "Aeronautical Decision Making" it "is decision-making in a unique environment—aviation. It is a systematic approach to the mental process used by pilots to consistently determine the best course of action in response to a given set of circumstances. It is what a pilot intends to do based on the latest information he or she has."

"The airline industry, motivated by the need to reduce accidents caused by human factors, developed the first training programs based on improving ADM."

In ADM they identified 5 hazardous attitudes:

I think we can all see parallels to diving accidents.

https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/phak/media/04_phak_ch2.pdf

 

[Nitrogenius]

I agree with this. Having said that, I wouldn't call it something new learned. I meant 'lesson' as in, is there somehitng new here. I reckon that some things in that group were considered normal or OK, that are generally considered safey violations in cave diving.

When you watch Gus's report of his incident, he doesn't acknowledge the issue. When someone asked about it on fb, a team member basically supported Gus's take.
Their surly were more issues and contributing circumstances, but IMHO it's essential that you really hammer down on the major issues.
That's my issue with the HF approach. I a bit too scatter-shot. The big issues need to be pointed out clearly and we more often than not know what they are.
With many accidents it's like 'oh, here we go again'. People should know what not to do when they have taken training and read books/reports. They just ignore it, over and over and over again. I don't know how to fix it, especially when people won't acknowlege the big issues to begin with.

Well and this is exactly what can be learned from it "new and old":
One does not have to reinvent the wheel but use "simply" actually use best practises.
This project clearly did not follow best practises in many angles.

So what to do about people just ignoring stuff they learned:
Work on creating an environemnt that does not tolerate deviation from what has been taught an d learned and established as best practises..
Create an environment that normalises (and not supresses) the admission of own mistakes for the benefit of learning from them!

Way easier said than done, but that is what is neede in my opinion and is what can be learned her (or just reinforces already establishe knowledge)
I think emphasising the "human factor" as Gerath Locke is lobbying for since quite some time is key here..
as well as learning from aviation industry which had to deal with these related topics for quite some time is helpful.

 

[Aura]

When you watch Gus's report of his incident, he doesn't acknowledge the issue. When someone asked about it on fb, a team member basically supported Gus's take.

You're referring to a prime example of a zero-to-hero who has collected a large entourage of fanatical followers who will endlessly confirm that he is the best diver to ever grace water with his presence, most of whom are non-divers. The arrogance to dismiss any criticism directed at the (often) unsafe things they promote on their social media is exactly the opposite of what we should strive for in threads like this.

Since you're asking for concrete things that can change as a result from this: I think this tragedy has, more than anything, shown us that pre-dive checks should not be left to the individuals, however skilled and experienced they may be. If I'm ever in an overseeing position of a project like this, I'll make damn sure that no diver who's my responsibility gets in the water without being sure their critical equipment works and that they're carrying the correct gases. No different than the (usually tedious) gear and radio checks done in the military before moving into hostile territory.

And I think it's the responsibility of every team member on any project to promote a culture in which it's encouraged to speak up about any potential issues the team or individuals in the team might face. That's something we owe each other.

 

[Nitrogenius]

I think we can all see parallels to diving accidents.

Excactly !!

 

[berndo]

So what to do about people just ignoring stuff they learned:
Work on creating an environemnt that does not tolerate deviation from what has been taught an d learned and established as best practises..
Create an environment that normalises (and not supresses) the admission of own mistakes for the benefit of learning from them!

Yes, I agree. But how do you go about it in practice? As you probably know, especially in tec diving. 'Cliques' will form around and instructor, a shop or a 'philosophy' (wink wink).
Most people are and stay on the beginner-ish side and look up to their instructor or head honchos in the group like kids to their mommy. It's quite tribal and people aren't well trained, full-time pilots but hobby dudes with often big egos and little experience.

While agree with your points, I don't see how this could be fixed in real life. I really have no idea. One approach would be to boot alot of crappy instructors and make agencies improve or get some kind of QC to begin with... but that's not going to happen. How would you go about 'creating an environment'? I have no idea.

You're referring to a prime example of a zero-to-hero who has collected a large entourage of fanatical followers who will endlessly confirm that he is the best diver to ever grace water with his presence, most of whom are non-divers.

Meh, I don't think that's fair, that could have been somebody else without any followers just as well. We just heard about it because he has a youtube channel. I have not met him but on the channel he doesn't seem to be more or less full of himselfs than many other people.