Special Rules - Please read

[Rick Murchison]

The purpose of this forum is the promotion of safe diving through Accident Analysis.
To that end, this is a fully moderated forum. That is, posts will not appear immediately, but will be sent to the Accident Analysis moderator team for review and compliance with Mishap/Accident Analysis protocols before posting. This may require some communication between you and the team, or between the team and third parties to make sure facts are facts before posts are made visible in a thread.
In addition to the normal TOS, the Mishap Analysis forum has the following rules:

(1) Events will be "scrubbed" of names of people and places. The only name you may use in this forum is your own.
(2) No "blamestorming." Accident analysis does not "find fault" - it finds hazards - and how to reduce or eliminate them.
(3) No flaming, name calling or otherwise attacking other posters. You may attack ideas; you may not attack people.
(4) No trolling; no baiting.
(5) Remember that you cannot read minds. Restrict comments to what happened and how to prevent it, without speculating on what someone else was thinking (or not). The only thoughts you are qualified to share are your own.
-- in addition --
(6) No "emoting" here; no anger, sadness, elation or condolences. Just the facts, the analysis of the facts, and the recommendations that flow from the analysis of the facts.

The analysis approach to mishaps is quite different from a "normal" investigation, which seeks to understand the mishap, including the motives and thoughts of the participants leading up to the decisions that resulted in the actions that led to the mishap. In addition, a "normal" investigation tries to assign responsibility and liability.
Accident analysis, on the other hand, identifies hazards.
Hazards are things that result in injury or death.
To accomplish this, the analyst only looks at what happened, that is, what the participants actually did, and what consequences those actions had. We do not assign responsibility, or liability, or try to understand why someone did something, because in the end analysis, none of those things bear on the result of the action. Actions or conditions that have harmful results are deemed hazards, and our objective is to identify them, then make recommendations on how to eliminate or ameliorate them.
To many this seems a cold, heartless approach to mishaps... but it is efficient and effective.
A simple example...
The mishap: Diver ventures into a cave, turns around with plenty of air, but takes a wrong turn, runs out of air and drowns.
One hazard that is readily identified is "taking a wrong turn in a cave."
The mishap analyst recommends "a continuous guideline to open water" as a way to ameliorate this hazard, and from that flows one of cave diving's rules "Always maintain a continuous guideline to open water."
Notice that we don't need to know the diver's name, age, sex, or training level. We don't need to know why the diver entered the cave, or why the diver made the wrong turn. The fact that the wrong turn was made and resulted in increasing the time in the cave beyond the air supply is enough to identify that as a hazard, and to formulate a recommendation to prevent it for future divers.
What we hope to accomplish here is to distill mishaps into identified hazards, and to come up with sound recommendations we can use to improve dive safety for us all.
Thanks in advance for your cooperation and participation in this effort.
Rick