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

[crofrog]

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.

What people learn first and who they learn it from first creates a very strong barrier to overcome later. If your instructor isn't modeling good diving habits from the very first dive (including things like analyzing gas) then it's going to seem less important than it is, and unfortunately, most diving instructors are the young I want a fun job for a bit and took an IDC variety and are trying to train people to dive in as few hours as possible, and they where trained in as few hours as possible.
One of the pioneers of educational psychology, E.L. Thorndike formulated three laws of learning in the early 20th century. [Figure 3-7] These laws are universally accepted and apply to all kinds of learning: the law of readiness, the law of exercise, and the law of effect. Since Thorndike set down his laws, three more have been added: the law of primacy, the law of intensity, and the law of recency

Primacy
When an error occurs pouring a concrete foundation for a building, undoing and correcting the job becomes much more difficult than doing it right the first time. Primacy in teaching and learning, what is learned first, often creates a strong, almost unshakable impression and underlies the reason an instructor needs to teach correctly the first time. Also, if the task is learned in isolation, it is not initially applied to the overall performance, or if it needs to be relearned, the process can be confusing and time consuming. The first experience should be positive, functional, and lay the correct foundation for all that is to follow.

Readiness
Learners best acquire new knowledge when they see a clear reason for doing so, often show a strong interest in learning what they believe they need to know next, and tend to set aside things for which they see no immediate need

Effect
Learning involves the formation of connections, and connections are strengthened or weakened according to the law of effect. The law states that behaviors that lead to satisfying outcomes are likely to be repeated whereas behaviors that lead to undesired outcomes are less likely to recur

Intensity
Immediate, exciting, or dramatic learning connected to a real situation teaches a learner more than a routine or boring experience. Real-world applications (scenarios) that integrate procedures and tasks the learner is capable of understanding make a vivid impression, and he or she is least likely to forget the experience.

Recency
The principle of recency states that things most recently learned are best remembered. Conversely, the further a learner is removed in time from a new fact or understanding, the more difficult it is to remember.

https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/aviation_instructors_handbook/media/05_aih_chapter_3.pdf

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.

It'll be solved by insurance agencies, probably for the worse when they continue to raise insurance rates or implement additional requirements for dive sites and instructors.

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.

Agreed, and it was good for them to share the event, although I don't think they focused on learning from it as much as just blaming the equipment configuration because the changing of gear is easier than evaluating their knowledge skills, and abilities.

 

[tomfcrist]

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.

I agree. That being said there is some merit to the zero to hero part. Not that Gus “fast tracked” his CCR certs or Cave certs, but in that he’s got just enough experience to be a bit overconfident. Human nature.

 

[grantctobin]

Not that Gus “fast tracked” his CCR certs or Cave certs,

Well…

 

[berndo]

Agreed, and it was good for them to share the event, although I don't think they focused on learning from it as much as just blaming the equipment configuration because the changing of gear is easier than evaluating their knowledge skills, and abilities.

I assume Gus just said what he was told by the more experienced guys on the team. He is basically in the position of the student and he is not complaining because he doesn't know better. He's probably got way less experience than other people in the team.
The questions on fb adressed to him were actually answered by someone else, for him.
I bet you, Gus didn't go to the project manager and said, 'hey yo, this config is BS', because he was scared or unconfortably. He learned from them... the student is usually not going to correct or argue with the trainer, and you can't expect them to.
I don't blame Gus.

It'll be solved by insurance agencies, probably for the worse when they continue to raise insurance rates or implement additional requirements for dive sites and instructors.

And why would that ever happen? The PADI business model hasn't really changed in the last 30 years as far as I can tell.

What people learn first and who they learn it from first creates a very strong barrier to overcome later. If your instructor isn't modeling good diving habits from the very first dive (including things like analyzing gas) then it's going to seem less important than it is, and unfortunately, most diving instructors are the young I want a fun job for a bit and took an IDC variety and are trying to train people to dive in as few hours as possible, and they where trained in as few hours as possible. ...

Yeah, sure. What's you're point though? (BTW: I was talking about the trimix/cave part of the industry and how that is cliquey rather than the OWD level, but anyway).
As you said, and I agree, lots of young people with very little experience and training doing it because it's a fun job. Another group is people fleeing alimony payments or the IRS in their home country, also with little training and experience. And then maybe 15% to 20% of actual professionals.

The business model is offering a 3-4 day class for relatively cheap to mostly tourists. This model has been working great for decates.
Why would padi or ssi want to make any changes to this? I also don't know how we got here from the HF stuff.

You and some other posters are making a purely philosophical argument. That's fine and dandy, I agree with these ideas, they all sound great, but in what way are you or anyone else going to implement any of this? If you have a plan, I'm for it.

 

[crofrog]

And why would that ever happen? The PADI business model hasn't really changed in the last 30 years as far as I can tell.

Do you have a background in safety critical industries, regulated industries or dealing with insurance for those fields.

It would happen because the insurance will stop under writing unless they feel like the risk is acceptable and that will drive change. If you’ve not been paying attention insurance for instructors is at an all time high.


I can only control what’s around me and what I choose to participate in if you look at GUE these concepts are fully baked in and Lock is on the quality management team.

 

[berndo]

If you’ve not been paying attention insurance for instructors is at an all time high.

In the US maybe, I don't pay attention to the US insurance market. I don't live there. PADIs and SSIs market is international.

I can only control what’s around me and what I choose to participate in if you look at GUE these concepts are fully baked in and Lock is on the quality management team.

GUE's system only caters to the very top end and a teeny tiny % of the market. And even there only to certain crowd. They are not even really in same business as PADI and never will be. Actually, GUE needs PADI and SSI.
If PADI went under, GUE would be screwed.

 

[formernuke]

True but PADI doesn't matter for this discussion. Gus did not get PADI certified

 

[PirateFoxy]

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.

Human Factors is psychology, it has nothing to do with how a rebreather works. Do you think learning to use a rebreather reprograms your entire brain such that you operate on an entirely different set of behaviors than everyone else?

Given that there is a wide variety of opinions on what is and is not "to be expected" from students in terms of self-reliance and level of assertiveness at everything after the most basic OW certification, you are making an incorrect assumption about how any given instructor will behave and what is and is not appropriate to expect of the students. Human factors would say that it's important to establish what *is* actually reasonable to expect from students, so that people's safety is not dependent on chance throwing compatible students and instructors together, or luck meaning nothing goes wrong during the class. Human factors would also ask what, if anything, needs to be done during the class to be sure the students behave as expected - for example if they are expected to be assertive and self-reliant, is there anything that should be done during the class to reinforce that and help them perform in that way?

These same principles apply to diving in a team scenario such as in this incident. Someone associated with the team said that they are sure that everyone knew the bail out tanks were for anyone - but they're speaking from their own perspective, and are unlikely to have questioned other divers on the team in such a way as to reveal how they really think about the tanks. (You have to be careful asking questions because what people will *do* and what people will *say* that they'd do are not always the same thing. Thus just asking "Do you know the tanks are for anyone?" may well not get answers truthful to how people actually behave in the moment. There have been experiments and incidents in the past when studying this sort of thing where someone says the correct thing to do/expresses the correct attitude, then *immediately* turns around and does something different because while they intellectually know the 'correct' answer, it isn't actually internalized as part of their standard practice/habits/etc.) So to evaluate the human factors elements in this incident, one thing you'd possibly want to do is try to find out what people's habits/practices actually ARE, versus what people might say they are to a direct question. You can do this by observing over time, by reviewing past incidents and past data on BO tank use, etc. etc.

Human factors is not a diving specific concept. It's quite broadly applicable and has had significant success in environments where it's been applied for a while, like aircraft. But it's not, and has never been, about identifying one single 'smoking gun' moment where everything went bad, because what we've discovered with all that time studying and applying human factors to various things is that incidents very very rarely are just one single 'smoking gun' moment - they are the product of a chain of behaviors and assumptions and attitudes that create an environment in which existing safety procedures and protocols fail such that something can happen that shouldn't. If that environment didn't exist, then if someone did something like set up to take the wrong gas with them on a dive, those safety procedures and protocols would catch it and so nothing horrible would happen. So the failure of the safety procedures and protocols - not just THAT they failed, but WHY they failed - is critical to improving things going forward. That is what human factors is about.

 

[PirateFoxy]

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.

Also try to understand why people might be deviating from what is being taught - there can be a variety of reasons why that happens and so the solution will also vary.

For example, in the airlines I believe there was an incident where as a result they changed the checklist procedure because they found that in making the checklists longer and more detailed to try to improve safety, things had gotten to the point where pilots simply weren't getting through the full checklist because of the time/effort involved when they also had other tasks to be attending to - and the design of the checklist meant that if you started and were halfway through and had to stop to attend to something else, starting over took quite a while and if the list item that will identify your problem is on page 20 of the list and you keep having to restart on page 10, the list is not really helping you. (I think in the particular accident that brought this to light, the crew didn't have time to get to page 20 even the first time around, but part of the goal of accident investigation is to improve things going forward, so you don't abandon a problem just because it wasn't the critical element in the accident you're looking at.)

So on the surface it looked like checklists were a reasonable solution that should work fine, but in practice it just didn't hold up due to the complexity that had developed, but that wouldn't be evident unless you observed the checklist in use over time to see the issue come up. The end result was checklists stayed, but they were redesigned and simplified to make them more practically functional. That's obviously a complicated example, but it can be as simple as "people aren't wearing this safety gear because it's too much hassle to go get it" - so you move the safety gear so it's stored closer to where it's needed to reduce the effort required. Or you know it can be that people just don't understand the protocol or procedure, or the point of it, in the first place, so you just need to change your teaching method a bit to get more compliance. But it's important to try to understand why so you can solve whatever problems exist.

 

[tomfcrist]

Well…

If you meet the course entry requirements set by an agency, are you really out of line and trying to move too fast? Faster than I like maybe, but my opinion is irrelevant. If Edd signed off on his cave dpv, he’s gotta be at least mechanically competent…the question really is whether he’s got the experience to see Swiss cheese holes lining up and challenge the status quo within a team setting. Sometimes you can gain that experience by reading about other folks mishaps or near misses, but often you have to survive your own near miss to click on the proverbial light bulb.