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

[Nitrogenius]

wow.. quite an active discussion now.. Hard to keep up from lunch break to lunch break.. lol

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.

Definately it is a job for the agencies vie enforcing certain standards and actually act upon violations. In order to make the agencies do that, likely peer pressure by the consumers (us the divers) has to be created that things would have to change. But that's what I meant easier said than done and certainly a loooong path and it will be a continuous effort .. again the parallel to the aviation industry. **** continues to happen there and they keep working to try to make it safer, while this trying is mostly circulating around the HF topic. Humans are stupid and insist to have the freedom to be stupid for th most part, so we have to try to navigate this minefield.

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.

Well that is apparently not working as avoidable accidents keep happening and insurances have been around the industry for ages..

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.

agreed..

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.

exactly! Human nature and that is the topic. How do we make it safer acknowledging the human factors!? I think the latter is a first step and this acceptance is moving very slow.. It would have to reach the highest levels of the agency to make them reconsider how the curriculums and IT training would have to be adapted.
Reminds me of Pyles learners guides and his quote:

"After my firt 10 hours on a rebreather, I was a real expert. Another 40 hours later, I considered myself a novice. When I had completed 100 hours, I rtealzied I only was a beginner. Now that I have spent more than 200 hour, it is clear I am still a rebreather weenie."

Seems gus is still at the 10 hour level..

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.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.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.)

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

absolutely! I completely agree

But it's important to try to understand why so you can solve whatever problems exist.

jepp exactly my point

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.

It is about the environment that caters to it. If there is folks seeing this a heroic and cheering, than it is difficult. If the peer pressure is there from the rest of the diving scene as that is something not to do, then it might be different. In regards to the youtube channel one does not have to forget about the money involved. The channel has almost 250K followers, that is serious money!
As for the own near miss and light bulb.. Well there goes the saying: "everybody can learn from their own mistake, smart folks learn from teh mistakes of others." Just saying

There is no chance they will change their approach to diving unless someone dies as a result of it. And that is exactly the problem.

Well that actually happened and yet any change to be noticed?

 

[Nitrogenius]

IMHO HF couldn't have prevented this accident.

I strongly disagree.. I think looking at HF is spot on when trying to understand how such a prestigious project could have been axecuted in the manner it did and how the near miss did obviously not lead to changing practises.
It might have made sense to revisit the practise of carrying "air-like" mixes on those dives (inlcuding the prep dive) to apparently just save a suitgas tank latest after Gus near miss.
The latter (saving a suitgas tank) being the reason for this kind of setup that I have taken away so far.

On the face of it we have someone that appeared to be rational acting irrationally unexpectedly.

Really? You define the reported gas choices as rational?
These choices that in the merit are questionable at minimum scream human factor all over in my opinion. The unexpectedly acting irrational was in my opinion only a result of the gas choices and configuration throghout the project. Also for the relatively unexperienced diver, that now unfortunatley can't gain any further experience, there is a good chance that human factor played a role in not questioning configuration and gas choices.

But you can use HF to look at ways to prevent it from happening in the future, like team verification of gases at analysis and when the tank is put in the water. Again IMHO HF is about preventing future accidents.

HF in my opnion is first about acknowledging that HF plays a role in diving and diving accidents!

 

[berndo]

Who said it was a knowledge problem? Fixing attitude issues, or minimizing their effect, is a big part of what HF is. So you saying HF is not the answer does not really make sense if you consider this an attitude problem. You could learn more about this from his books or classes.

I don't want go through this again. I'll try and clarify with an specific example. See what I wrote initially:

don't think his breakdowns are wrong and I like to read his stuff but don't think it's all that helpful either. He tends to pile up a bunch of factors that have possibly contributed to a bad outcome, fair enough, but IMHO neglects to hammer down on core issues that actually cause the accidents.

My critique was about the application of the system not of HF itself.
Here is the example. In the film he mentions the non-standard configuration of the unit. Can this be a contributing factor in some cases? Surly, but in this particular case it wasn't. The conduct of the instructor stuff should have gotten more attention.
IMHO, he should have focused more on things that, in fact, were huge issues and spend less time on stuff that could have in another case. After all, this film was about a specific case. Not, a general introduction into HF.
I'm not surprised the instructor wasn't available for an interview.

I have messaged with Gareth about another case with a simular point and he seemed happy to talk about it and actually adressed my point.

 

[steinbil]

I don't want go through this again. I'll try and clarify with an specific example. See what I wrote initially:

My critique was about the application of the system not of HF itself.
Here is the example. In the film he mentions the non-standard configuration of the unit. Can this be a contributing factor in some cases? Surly, but in this particular case it wasn't. The conduct of the instructor stuff should have gotten more attention.
IMHO, he should have focused more on things that, in fact, were huge issues and spend less time on stuff that could have in another case. After all, this film was about a specific case. Not, a general introduction into HF.
I'm not surprised the instructor wasn't available for an interview.

I have messaged with Gareth about another case with a simular point and he seemed happy to talk about it and actually adressed my point.

HF was brought up in this case because it’s relevant for the accident in question. Why you feel the need to criticise this unrelated movie is not clear, unless you meant it as a general critique of HF or its relevance to the incident in the OP.

I think @crofrog summed it up nicely in post #506.

These are lessons that might not be new, but if they are to be implemented, people need to take the human factors seriously. If we don’t plan for human error, it‘s only a matter of time before something like thos happens again.

 

[lostsheep]

I don't want go through this again. I'll try and clarify with an specific example. See what I wrote initially:

My critique was about the application of the system not of HF itself.
Here is the example. In the film he mentions the non-standard configuration of the unit. Can this be a contributing factor in some cases? Surly, but in this particular case it wasn't. The conduct of the instructor stuff should have gotten more attention.
IMHO, he should have focused more on things that, in fact, were huge issues and spend less time on stuff that could have in another case. After all, this film was about a specific case. Not, a general introduction into HF.
I'm not surprised the instructor wasn't available for an interview.

I have messaged with Gareth about another case with a simular point and he seemed happy to talk about it and actually adressed my point.

Maybe I missed it, what film and what instructor are you talking about here?

 

[steinbil]

Maybe I missed it, what film and what instructor are you talking about here?

If only

 

[berndo]

Why you feel the need to criticise this unrelated movie is not clear, unless you meant it as a general critique of HF or its relevance to the incident in the OP.

It's a specific example, I used early on to explain something. It's not at all unrelated. You kinda have to read the thread.

Stop tagging me.

 

[formernuke]

Guy taking a mod1 class died. He did some stuff wrong as did the instructor.

Failing to see how it's relevant to thus thread though.

 

[berndo]

Failing to see how it's relevant to thus thread though.

You don't see how a something from a video about a HF analysis is used as an example in a discussion about HF?
Nevermind

 

[lermontov]

"After my firt 10 hours on a rebreather, I was a real expert. Another 40 hours later, I considered myself a novice. When I had completed 100 hours, I rtealzied I only was a beginner. Now that I have spent more than 200 hour, it is clear I am still a rebreather weenie."

that is so true - ill add to it-
when we look at others along the path weve already gone look at their gear set up and decision making and cringe, bear in mind theres probably someone ahead of us looking back at us doing the same