Analysis, Part 2
Before I begin, I would like to say that I'm not looking for any work from this. I have been analyzing diving accidents for many years now, and have not received any income from that endeavor. However, since I have been in the safety profession for over 30 years, and have insights others may not know of, I feel the need to give my own thoughts about these situations.
Concerning this particular situation, it is based only upon the above commentary. This may or may not be completely accurate. Normally, for an in-depth accident analysis, the persons involved are interviewed in detail, about the events, the time lines, the protocols, the responses, actions and inactions, etc. Without these inputs, an actual complete analysis is not possible. However, some generalized observations can be made.
Specific Measures
Dan Peterson's Model 3 can be used to give some perspectives that we all can take away from this situation. We will be looking at the right side of this flow diagram (the top and left side were discussed in a previous entry). Here is that model again:
If we look at the center three items of this right side, for the specific situation, we see that we all have a capacity with a load in a state, to paraphrase Dan Peterson.
Our capacity changes day-to-day, and even with the time of day. For instance, I am now 66 years old. I don't have the capacity I had when I was a Pararescueman in my late 20s or early 30s. While I can still handle twin-tank scuba, I probably would have trouble with 150 pounds of gear on a parascuba jump. So capacity changes. We need to understand that, and if a situation develops which could put us in jeopardy, feel free to call it and abort.
The load can also change. This can be a physical load, or a mental road. For instance, using rental gear that a person is unfamiliar with will tax a person mentally, as the dive suit, buckles, the regulator(s) and the BC will be in different positions, have different buoyancy characteristics, and different orientations. This causes a "load" on the diver.
The "state" is the state of mind. For someone expecting an orientation dive, and then not being supported, the "state" will be of anxiety rather than relaxed confidence. This anxiety was apparently expressed to the boat captain.
Capacity can be changed with training, and a good orientation, briefing, discussion of emergency procedures, etc. can help increase the diver's capacity to dive in a particular situation. The load can be analyzed using what we in the safety profession call a "Job Safety Analysis", or JSA. In a JSA, the steps for any process in the jobsite are determined, then the hazards of each step, with the safety precautions and personal protective equipment (PPE) required for each step is determined. This is done in a table format.
The diver's "state" can also be changed, through good rest, preparation, nutrition, etc.
So on any given date, our capacity with a load in a state changes, and we need to recognize this and ensure that our capacity is such as to be able to handle the situations as they develop. This is what your scuba training is supposed to do.
There are two sections of this part of the flow chart we have not yet discussed. These are the "Decision to error" and the "Traps" that are set for us.
The "Decision to error" can occur because of group pressure, because of internal conflicts, or many other things. We do this sometimes in our driving, by not completely stopping for a stop sign, for instance. Sometimes it is a group decision, an "egging on" or a dynamic that says we can do something we know is a stretch. It may take a very strong-willed person to go against this group decision. Dive instructors should probably reinforce that there will be those times when a new diver should go against the group decision if the diver feels that the dive is more than his or her capacity at a particular time. We all should say that once in a while. If I had done this for a dive in 1973, my buddy and I would not have spent about 4 hours trapped off the Oregon coast, and needing rescue by the U.S. Coast Guard (but that's another story).
Now, let's talk about "traps". In diving, there are many potential "traps", and our training helps us to overcome them by enlightening us about them. How many of us would know about decompression sickness if we had not undergone our scuba training? Part of our instruction has to do with emergency procedures, or how to get out of a "trap". The trap can be a malfunctioning piece of gear, or being overweighted, or having a failure of a dry suit in extremely cold water. Each of these instantly impacts the "loading" of the diver in a situation.
Richard, in the post above this one, proposed a means of potentially ranking a particular dive. In the safety profession, we call this "risk ranking" and it is a very useful tool (though the standard is much different, and we don't have space to go into it here). But each of us has the ability to look over a particular situation, and make a determination as to whether it is safe for us to try on that particular day, with are particular capacity, the environmental and equipment load, and our particular state at the time. If there is something to take away from this situation, is is that we need to make these evaluations each and every time we go diving (or for that matter, in other activities too).
The whole idea of dive safety is to put into place both the individual (specific) survival tools though training, equipment design, etc., and the organizational tools (SOPs, emergency procedures, orientations, briefings, etc.) to ensure a safe diving experience. If this is not happening, then it is both the organization's and the individual's joint responsibility to "call" the dive, and not get into the water.
John C. Ratliff (SeaRat), CSP, CIH, MSPH
John is a Certified Safety Professional, Certified Industrial Hygienist, and has his Master of Science in Public Health, with an emphasis on safety and industrial hygiene. John is also an ex-NAUI instructor (#2710), ex-USAF Pararescueman, and has been actively diving since 1959. He writes regularly on the Vintage Equipment portion of ScubaBoard.
Before I begin, I would like to say that I'm not looking for any work from this. I have been analyzing diving accidents for many years now, and have not received any income from that endeavor. However, since I have been in the safety profession for over 30 years, and have insights others may not know of, I feel the need to give my own thoughts about these situations.
Concerning this particular situation, it is based only upon the above commentary. This may or may not be completely accurate. Normally, for an in-depth accident analysis, the persons involved are interviewed in detail, about the events, the time lines, the protocols, the responses, actions and inactions, etc. Without these inputs, an actual complete analysis is not possible. However, some generalized observations can be made.
Specific Measures
Dan Peterson's Model 3 can be used to give some perspectives that we all can take away from this situation. We will be looking at the right side of this flow diagram (the top and left side were discussed in a previous entry). Here is that model again:
If we look at the center three items of this right side, for the specific situation, we see that we all have a capacity with a load in a state, to paraphrase Dan Peterson.
Our capacity changes day-to-day, and even with the time of day. For instance, I am now 66 years old. I don't have the capacity I had when I was a Pararescueman in my late 20s or early 30s. While I can still handle twin-tank scuba, I probably would have trouble with 150 pounds of gear on a parascuba jump. So capacity changes. We need to understand that, and if a situation develops which could put us in jeopardy, feel free to call it and abort.
The load can also change. This can be a physical load, or a mental road. For instance, using rental gear that a person is unfamiliar with will tax a person mentally, as the dive suit, buckles, the regulator(s) and the BC will be in different positions, have different buoyancy characteristics, and different orientations. This causes a "load" on the diver.
The "state" is the state of mind. For someone expecting an orientation dive, and then not being supported, the "state" will be of anxiety rather than relaxed confidence. This anxiety was apparently expressed to the boat captain.
Capacity can be changed with training, and a good orientation, briefing, discussion of emergency procedures, etc. can help increase the diver's capacity to dive in a particular situation. The load can be analyzed using what we in the safety profession call a "Job Safety Analysis", or JSA. In a JSA, the steps for any process in the jobsite are determined, then the hazards of each step, with the safety precautions and personal protective equipment (PPE) required for each step is determined. This is done in a table format.
The diver's "state" can also be changed, through good rest, preparation, nutrition, etc.
So on any given date, our capacity with a load in a state changes, and we need to recognize this and ensure that our capacity is such as to be able to handle the situations as they develop. This is what your scuba training is supposed to do.
There are two sections of this part of the flow chart we have not yet discussed. These are the "Decision to error" and the "Traps" that are set for us.
The "Decision to error" can occur because of group pressure, because of internal conflicts, or many other things. We do this sometimes in our driving, by not completely stopping for a stop sign, for instance. Sometimes it is a group decision, an "egging on" or a dynamic that says we can do something we know is a stretch. It may take a very strong-willed person to go against this group decision. Dive instructors should probably reinforce that there will be those times when a new diver should go against the group decision if the diver feels that the dive is more than his or her capacity at a particular time. We all should say that once in a while. If I had done this for a dive in 1973, my buddy and I would not have spent about 4 hours trapped off the Oregon coast, and needing rescue by the U.S. Coast Guard (but that's another story).
Now, let's talk about "traps". In diving, there are many potential "traps", and our training helps us to overcome them by enlightening us about them. How many of us would know about decompression sickness if we had not undergone our scuba training? Part of our instruction has to do with emergency procedures, or how to get out of a "trap". The trap can be a malfunctioning piece of gear, or being overweighted, or having a failure of a dry suit in extremely cold water. Each of these instantly impacts the "loading" of the diver in a situation.
Richard, in the post above this one, proposed a means of potentially ranking a particular dive. In the safety profession, we call this "risk ranking" and it is a very useful tool (though the standard is much different, and we don't have space to go into it here). But each of us has the ability to look over a particular situation, and make a determination as to whether it is safe for us to try on that particular day, with are particular capacity, the environmental and equipment load, and our particular state at the time. If there is something to take away from this situation, is is that we need to make these evaluations each and every time we go diving (or for that matter, in other activities too).
The whole idea of dive safety is to put into place both the individual (specific) survival tools though training, equipment design, etc., and the organizational tools (SOPs, emergency procedures, orientations, briefings, etc.) to ensure a safe diving experience. If this is not happening, then it is both the organization's and the individual's joint responsibility to "call" the dive, and not get into the water.
John C. Ratliff (SeaRat), CSP, CIH, MSPH
John is a Certified Safety Professional, Certified Industrial Hygienist, and has his Master of Science in Public Health, with an emphasis on safety and industrial hygiene. John is also an ex-NAUI instructor (#2710), ex-USAF Pararescueman, and has been actively diving since 1959. He writes regularly on the Vintage Equipment portion of ScubaBoard.
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