Whose fault is it when an accident happens?

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tedtim:
The TOS for this particular forum ask us to look at accidents from the perspective of finding lessons that we can apply to our own diving. IMO, focusing on blame, how to determine who is to blame, or otherwise how to assign blame is not productive.

There are those that equate cause with blame. So be it. I don't see it that way.

Thanks for taking the time to read the TOS, something some folks don't do! :D

Blame (for lack of a better word) is a key component of accident assessment. The blame leads to the next steps required in accident prevention.

For example:

Accident, diver dies.
Cause, First stage Malfunction.

Now WHAT needs to be done to prevent this in the future. IOW's what, or whom is to blame, and how can that be corrected.

Possible answers:

1) The equipment has NEVER been serviced over several years, and hundreds of dive. The Blame is on the diver, and future prevention is to adhere to recommended service intervals.

2) The equipment had a manufacturing defect. The Blame is on the manufacture quality controls, and future prevention is to fix that process.

3) The equipment had a design defect. The Blame is on the engineer, and the future prevention is to recall the defective equipment, and change the design.

So Blame is a very important part of the equation as it explains not just what, but why something occurred. Discussing blame or fault is not in violation to the TOS, rather a key part of the discussion from my perspective.
 
Assuming that the students did violate a DECO model (computer or table) I think that in this situation the fault lies with the students AND with their instructor.

Heres why I blame them both:

The instructor for allowing his/her students to staydown past the NDL without decompression and the students for not taking responsibility for their own DECO limits and surfacing with or without the instructor if it came with that.

If they did not violate and DECO rules ie stayed on the damm table and this was a undeserved hit then it goes up as SH** Happens and no one is at fault.
 
Regardless of fault or blame or even the chain of events that lead to the accidents- the buck stops with the diver when the wetsuit hits the water- even with bad or faulty gear- divers are taught ways to mitigate those dangers- redundant air, air sharing, even CESA :11:.

Of course, in this particular case, two bent divers sounds suspicious. :D
 
i would have to say if you are talking about someone taking a DCS hit it would have to fall back on an instructor or the diver. In the training the instructor or instructors should make sure that new divers are aware of some of the factors that can lead up to getting bent. and it is not a bad idea to review these with trained divers when taking other courses even if it is not part of the course. now if the divers are aware of some of the things that could cause them to get bent and ignore it than they are asking for trouble if it happens or not. if that is the case than i would say it is the divers fault and noone else. but most of you are right the question is very vague and you need to ask a specific question and not have such a broad range of area for discussion
 
I think we could look at "recreational diving" as a system. We market diving to people who don't dive. We train them, certify them and the industry provides oportunities for them to dive (resorts and charters) based in part on cridentials that we issue.

Once we define the scope and intended function of the system, we can measure the capability of the system. The capability of a system is a function of the overall system and not necessarily any one single component.

We tend to only look at catastrophic failures like fatalities and injuries. I'm not aware of any system analysis method in which this would be considered correct or effective. The idea is to measure, monitor and control system performance in a manor that avoids catastrophic failures. When there is a catastrophic failure, containment and corrective action is called for. The dive industry does none of this in a manor that would be considered adequate in any other industry. This is demonstrated by the fact that we don't see any improvement.

Lets look at a couple of examples.
As a very physically fit adventurous young man who was completely at home in the water, I got my hands on some dive equipment and just went diving. The scope of this system is pretty limited. Nobody sold me on anything, nobody trained me, nobody was in the water with me...it was just me and nobody made any decisions or had any control except me. Incidentally, it all worked out GREAT and I had a blast.

Another example...a 55 year old, out of shape, couch potato of 30 years who can barely swim sees an advertisement colorfully depicting the great joy and exceitement of visiting the underwater world. He/she decides to inquire at a local dive shop and they are told how easy, quick and convenient the training process is and how diving is great and "safe" for just about everyone including the 10 year old kiddies. This person is now talking to the experts. Our potato, joins in a class and limps through the minimal required skills planted on the bottom. The experts now award our potato with a certification and sell him/her a dive trip or several.

Now then, Mr/Mrs potato has consulted the diving experts and prudently followed their advice learning each skill to the required and recommended level of proficiency. Mr potato now has every reason to believe he is qualified. On a Sunday afternoon dive at Gilboa (maybe during an AOW training dive) our potato experiences a free flowing reg and suffers a rapid ascent resulting in AGE and dies.

What was the cause? The advertisement that got this non-adventurous out of shape non water person to consider diving? The experts at the dive shop who further sold, trained and qualified our potato? The agency who designed the training requirements for both the instructor and the diver? God because He made the water cold? Or maybe you think that the diver came to be in this situation all on his own with no outside influence?

Sorry, it's a system thing. Failures exist because there are flaws in the system. The system can not become more capable unless those flaws are identified and corrected. Do what you always did and you will get what you always got.

Oh...come on lets go diving. It's easy, you'll love it and you don't need to be a swimmer or have much experience in the water. Kneeling is just fine and there is no need to learn to manage problems midwater. It's easy, just do what I say because I know all about this stuff. I'm an expert...see here's my instructor card. Ooops, sorry Mrs potato but Mr potato died because he should have known better to listen to me in the first place. Don't be concerned though because this only happens 100 or so times a year in the DAN reporting area. We see no need to evaluate or modify our practices. We have deemed our performance to be "good enough" and have no desire to improve anything other than our gross sales. We don't acknowledge any correlation at all between our training standards that only require crawling and bouncing and the crawling bouncing potatos that occassionally bounce all the way to the surface and spit their lungs out their face or drown before reaching the surface. We have enough excuses to last a lifetime and some very good attourneys to write our liability releases. It's all made really easy by the fact that divers want to believe what we tell them and choose to defend our practices, their skills and their cridentials rather than taking a real close look at this. All the while patiently waiting and even paying to stand in line for their turn to shoot to the surface and spit their own lungs out. I, the agency or instructor, am off the hook and have no responsibility at all in this.

Well folks, maybe the rest of the industry is comfortable with this but as a former dive shop owner, PADI instructor and IANTD instructor I'm not. I don't let myself off the hook and there isn't a chance in hell that I will let the rest of the industry off the hook either! I am all for personal responsibility and the first people that I want to see take responsibility for their actions is the key players in the industry...the founders of the feast.
 
I think, in the vast majority of cases, diving accidents fall back upon the diver. Faults in technique with or without compounding lapses in judgment, lead to a situation the diver doesn't have the skills to cope with. Root causes could include marginal instruction, which may or may not be as a result of minimal agency standards. Those questions get debated endlessly here, and perhaps to some end benefit, as some divers become aware that their own training may have holes in it, and some instructors may see that more thorough training is possible within the agency paradigms.

But I have real problems with accidents while under instruction, especially with OW classes. Granted, nobody can predict exactly what someone is going to do underwater, and no instructor can be 100% effective in preventing and controlling all mishaps. But I suspect many problems could be avoided if people weren't taken to open water until they were truly ready for it. I sure wasn't.

Even if the accident occurs during advanced or even technical training, I think one must always look hard at the instructor. For example, if the two bent divers were doing AOW, or a deep specialty, did they stay down too long (something the instructor should have been monitoring)? Did they not have sufficient buoyancy control to hold safe stops coming up from significant depth? Did they have some malfunction (eg. freeflow) that addled them and led to an unsafe ascent? We don't know the answer to these questions, but they bring up places where an instructor might have been able to change the class to avoid an accident.

I'm experienced enough now that I'd blame myself for just about anything that happened to me, except maybe a tank of bad air. But I know I'll push my limits much further under instruction than I will diving on my own, and I trust my instructor to be wary and choose stresses he has confidence I will be able to manage, and to take whatever precautions he can to be in the best position to help, should I prove unable to rise to the challenge. That kind of thing can get dicey as the training gets more intense -- I remember reading a description from GDI of a tech training dive gone bad, and what he had to do to salvage the situation, and it was hairy.

So accidents can and will happen, but I think one must look long and hard at accidents that occur under instruction.
 
RonFrank:
Blame (for lack of a better word) is a key component of accident assessment. The blame leads to the next steps required in accident prevention.
On this point, you and I disagree, specifically that blame is a "key" component. To me, blame implies that someone did or did not do something that they ought to have known would have caused the accident. This is why insurance companies have a field day when it comes to lawsuits and determining who pays what.

In the end, a decision, or series of decisions was made or not made by an individual and this was the precipitating chain in the cause of the accident. Why did they make or not make the appropriate decisions? Training or lack thereof? Lack of adequate skills despite proper training (that is, deterioration of skills)? Bad advice, taken out of context or with more emphasis than it should have had in the decision tree? A lack of understanding of the environment? A lack of understanding of the consequences of actions? Human error?

Sorry, but if the first thing we are going to do is look for blame, then we will truly not be able to find out the chain of events leading to an accident. Each bit plays a part that leads to the decision taken. Looking for someone to blame places too much weight on the human error aspect and ignores the other contributing factors.
 
TSandM:
So accidents can and will happen, but I think one must look long and hard at accidents that occur under instruction.

I agree. With the current trend to slam divers through OW, it's a given that a certain percentage of accidents are going to occur. If changes are not made to the "system", as Mike states, then these issues will remain constant to some degree. The current trend of overweighting divers and "slamming" them down to the platforms to do skills is a big part of the problem in my opinion. I hate platforms just for that reason. Get them 2-3 feet over it then do the skills. Telling a diver to kneel in the muck and "not move around too much" while he sets up for a search and recovery operation is just wrong. It reinforces laziness. Then you take these divers out from the platforms to do "dives" and run into all sorts of buoyancy related issues. You got one diver overweighted having a runaway ascent and another diver decending rapidly. An instructor over here chasing this one and the divemaster chasing another while a third comes up to you 'cause he's low on air.

This is from personal experience. I see it all the time. And yes, as a Divemaster I can only do so much as an assistant.

I blame this on Instruction. Most of it could have been fixed IN A POOL before OW.
 
I think we could make a strong case for the idea that the less experience one has, the greater the reliance on the experience and judgement of others. Sort of like a trust-me dive. If I get you to trust me and you take my advice, I have some responsibility because my actions have a great effect on the outcome regardless of whether or not that equates to liability.

You know what they say about hindsight? When I was a new instructor I was NOT a very experienced diver and I had almost no instructional experience. I trusted the standards and judgement of the agency and the student trusted my judgement. In hindsight, I view most of that trust to have been sadly misplaced and ill-founded.
 
RiverRat:
Then you take these divers out from the platforms to do "dives" and run into all sorts of buoyancy related issues. You got one diver overweighted having a runaway ascent and another diver decending rapidly. An instructor over here chasing this one and the divemaster chasing another while a third comes up to you 'cause he's low on air.

This is from personal experience. I see it all the time. And yes, as a Divemaster I can only do so much as an assistant.

I blame this on Instruction. Most of it could have been fixed IN A POOL before OW.

Needless to say, as a DM and as an instructor I had the same type of experiences many times and I've witnessed the classes of other instructors doing the same at dive sites pretty much all over a good portion of the country. In the beginning I expected it and thought it was completely normal because that's all I had ever seen. It really is amazing how much it took to change my thinking.

LOL you all know how I harp on being midwater and learning midwatewr skills, right? There was a time when I about had a knock down drag out with a DM candidate because he was demonstrating mask R&R midwater and I wanted him on the bottom. When he asked why, I explained that I wanted him to demonstrate it the way I wanted students to do it. LOL, I hadn't yet considered why I should really want the student on the bottom.

When I first started teaching I had a well seasoned DM working with me. Once I was leading an OW class on a tour (pack diving) with the DM bringing up the rear. Vis wasn't so good (I wonder why) and I couldn't see all the way back to the DM so I stopped to make sure everyone was there. When I stopped, some shot to the surface and some plowed into the bottom and then I couldn't see anybody.

Later the DM pulled me to the side and suggested that I keep OW tours moving and NEVER stop. It really was quite a while and quite a few students later before I ever started thinking that there was something wrong with this concept. Again, it's all I had ever seen.

When my wife first started DMing she HATED to go into OW with students. She'd do almost anything to get assigned another job. Of course she hadn't been diving all that long either and it hadn't been very long since she stopped shooting to the surface. She used to disappear all the time. I'd look over and she'd be gone again. I always knew where she was though...at the surface. I'd see she was gone, stop, look up and wait for her to come back down. What a monster cluster.

Once we were in Arkansas visiting family and we went for a dive with my cousin. I'd have to check my log but I'm pretty sure my wife was a rescue diver by then. He was in front leading (we didn't know how team members should be positioned either). My wife shot to the surface and niether my cousin or I noticed. My wife came plumiting back down on top of me smashing me down into the bottom almost cracking my skull. She got off of me and took up position along side me but my cousin turned around just in time to see me literally climbing up out of the bottom in a giant cloud of silt. He's still trying to get me to tell him what I was really doing. LOL
 

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