Post-dive analysis and minor incidents

(not sure if this should be in the Mishap Analysis sub-forum. Mods, feel free to move the thread as considered appropriate)

A very popular concept in systematic HES work - at least in my part of the world - is the "incident pyramid". It's somewhat related to BSAC's classical incident pit concept, but it's upside down. Basically, what the incident pyramid theory says is that for each fatality, there's ten serious accidents. For each serious accident, there's three minor accidents. For each minor accident, there's twenty incidents without injuries or damage¹. So what? Well, if you want to work systematically to reduce the number of fatalities and serious accidents, there's just not enough of those to see any patterns. So, you start at the bottom of the pyramid, with the minor incidents. There's a lot of them, so you have the opportunity to see patterns. Also, if you work systematically to reduce the number of minor incidents, you'll reduce the number of minor accidents, reduce the number of serious accidents and, if you work well and are lucky, you'll reduce the number of fatalities to zero.

I've taken to applying this method to my own diving. After almost every dive with my regular buddy, we review the dive. What did we do right? What didn't we do right? (If I've been diving with an instabuddy, I try to do the same thing by myself, since I know that quite a few people will consider me a hysterical safety freak if I try to do it with them) Generally, if the first response is "everything was OK, nothing went wrong", I reconsider. There's always something which didn't work out quite as it should. At least 99 times out of a hundred. No-one is perfect - I know I'm not - and we all make errors. Actually, if we can't find any fault with the way we dived, it's an indication that we didn't have enough focus on safety and skills.

Do you analyze your dives? Do you search for minor errors and possible improvement, or are you happy with the way you dive? Myself, I try to never be happy with the way I do things. I know I'm human, and humans make errors. I do, too. And I know that my wife will be seriously pi$$ed off at me if I go and get myself killed or seriously injured through stupidity or recklessness. I really don't want my wife to be seriously pi$$ed off at me, even if I were dead...


¹ Don't get hung up over the numbers. The ratios really aren't important. It's the principle that counts.

I log each dive not just by recording numerical data but by writing a diving diary. It contains a profile, possibly pictures, and an analysis of the dive: what went exceptionally well, what needs improvement, what mistakes were done and in what order and why. This analysis is very important. I tend to highlight the minor problems with yellow and collect a to-do list at the last page, where I can check issues fixed. For more demanding dives I write a plan first, and compare result to plan last. I will also record the actions and co-operation of the team. I usually do all this alone.

Usually the analysis is just a short description of what was been seen, but if things go wrong, I tend to be verbose and analyze thoroughly. My unfortunate record is 10 A4 pages of buddy-reviewed analysis. And yes, I also have a red highlighting pen.

I keep this log on paper. Computers distract with all those bells and whistles.

The diving subculture of which I am a part encourages this -- the dive isn't really over until the debrief is done. It can be things as simple as, "Was the pace acceptable to everybody?". "Was the communication good?". Or if a dive has gone a bit sideways, it can be quite a bit more complex.

Not only does this improve safety, it improves teamwork. Only by talking it over can you find out that your buddy was frustrated the whole dive because you were moving too fast (or too slow), or because you were never quite where he could see you, or because you kept turning your fins toward him and kicking him in the face. When you work out those issues, the buddy relationship gets much better.

I couldnt agree more with both of you. Although unlike TS&M I probably dive with a not so regimented clture. The process is a sound one and is successfully done without stepping on ego's. I however am more regimented than most in regards to process and not so much in regards to the extent of the process. By that I mean,,,, so long as there is a post brief and something is discovered that went right or wrong, it far outweighs the need to cover all aspects of any dive. Simple things like a lost member with no light. The conversation goes llike this. where did you go? couldnt find you for a couple of minutes. I shined my light and was about to head for the surface when you showed up. (buddy) Yea i saw your light and that is how i found you. I guess i need to get a light. Can i borrow one of your's till i get one?. Every one is happy, safe and is one step closer to being the best they can.

Good thread and good ideas everyone.

Only when something goes wrong. Aside from that I figure if I'm around to ask questions I did it right.

KWS:

so long as there is a post brief and something is discovered that went right or wrong, it far outweighs the need to cover all aspects of any dive. Simple things like a lost member with no light. The conversation goes llike this. where did you go? couldnt find you for a couple of minutes. I shined my light and was about to head for the surface when you showed up. (buddy) Yea i saw your light and that is how i found you. I guess i need to get a light. Can i borrow one of your's till i get one?. Every one is happy, safe and is one step closer to being the best they can.

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This is IMO the way to do it. You don't need to make a big deal out of it. Look for the small things that do happen, but which could have been avoided. Be aware of them and work to avoid them next time. Make sure you paddle around on the surface if the incident pit, don't even dip below the surface. If small things happen regularly, there's a bigger risk of one of those small things teaming up with another small thing happening, and suddenly you are on your way down into the incident pit. Then a third smallish thing happens because you've accepted those incidents during your regular diving and written them off as insignificant - which they are, if they happen alone - and you find yourself in the middle of a CF. Bottom of incident pit, here I come.

Again, if you look at systematic HES work, workers are encouraged to report incidents. Incidents always happen, and a low number of incident reports is a bad thing because that means that 1: incidents aren't reported and 2: you don't get the data from which you can see the patterns. 3: you don't know what you should do to reduce risks and injuries.

The incident pyramid approach has been proven to work in industry, why shouldn't it work on my diving?

Subcooled:

I log each dive not just by recording numerical data but by writing a diving diary. It contains a profile, possibly pictures, and an analysis of the dive: what went exceptionally well, what needs improvement, what mistakes were done and in what order and why. This analysis is very important. I tend to highlight the minor problems with yellow and collect a to-do list at the last page, where I can check issues fixed. For more demanding dives I write a plan first, and compare result to plan last. I will also record the actions and co-operation of the team. I usually do all this alone.

Usually the analysis is just a short description of what was been seen, but if things go wrong, I tend to be verbose and analyze thoroughly. My unfortunate record is 10 A4 pages of buddy-reviewed analysis. And yes, I also have a red highlighting pen.

I keep this log on paper. Computers distract with all those bells and whistles.

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That is some anal retentiveness. I just cannot be bothered.

From wiki:
In Freudian psychology, the anal stage is said to follow the oral stage of infant or early-childhood development. This is a time when an infant's attention moves from oral stimulation to anal stimulation (usually the bowels but occasionally the bladder), usually synchronous with learning to control his or her excretory functions. In other words, toilet training. Freud theorized that children who experience conflicts during this period of time may develop "anal" personality traits, namely those associated with a child's efforts at excretory control: orderliness, stubbornness, a compulsion for control. If these qualities continue into later life, the person is said to be "anal-retentive".

Texasguy:

That is some anal retentiveness. I just cannot be bothered.

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I fail to see your point (provided your point is more than just threadsh!tting).

There are a couple of guys in my club who remind me of what I get from your post. I don't like diving with them; their attitude makes me feel uncomfortable underwater, and I don't appreciate feeling uncomfortable underwater.

I am surprised I have to explain myself. It is sheer logic. Subcooled describes how he is logging his dives. If you will read through his description, you will notice that he goes miles beyond normal logging. In psychology, it is referred as anal retentiveness, it is a term but not a clinical one. From Subcooled description, it seems that such orderliness and thoroughness is a textbook example of onset of an obsessive-compulsive disorder. There is nothing wrong with having one. I, for one, feel compelled to reply to certain posts, for example, like this one.

PS: We are everywhere!