Dan - Human error in diving

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Nice read ,it kind of follows what my thoughts were anyway
 
What Dan of DAN is saying is true, but only in the most general sense, when you get down to specifics what Dan is saying makes much less sense. It goes like this, of all the people who died in diving accidents who entered the water, most would still be alive if they had not made the human error of entering the water. While that is true, let's say that one of these people who entered the water died as a result of being stung by a cubomedusa. Would that be human error, because the diver choose to enter the water? Or would that be human error because the diver had a patch of exposed skin where he or she got stung? Or would that be human error because the diver failed to see the almost transparent jellyfish? On the other hand, was that not a matter of human error but rather an accident, a statistical risk, a stochastic anomaly?

Dan would have you believe that, "In the majority of cases, these triggers came down to human error – it was not the sea or body of water that divers were in that caused a problem, it was their own poor decisions, lack of training, experience or skills that resulted in an incident." Let's look at his categories:


  1. Poor Decisions: indeed some people make poor decisions and die as a result. Some people make decisions based on their level of knowledge, which is tied to training, and die as a result. In either case the issue was human failure, in the former error on the part of the diver and in the latter, error on the part of the instructor/course/LDS/agency/etc. But the idea of human error usually rides with an error made by the victim, and unless you can say that failure to detect the shortcomings of the instructor/course/LDS/agency/etc. are a form of human error, one really must partition between to the two and not just stampede down the path of human error.
  2. Lack of Training: training comes in many forms, from reading a book to formal classes. But, it is usually a poor decision (see above) to go dive if you lack any form of training in diving. Some do just fine without class based training, but these are your naturals: ocean swimmers, free divers, surfers, you know, ocean people; or are competent ocean people going where they shouldn't without additional training, e.g., caves, wreck penetrations, etc. I submit that accidents that can be traced directly to a lack of training need to be split into two types, accidents caused by the POOR DECISION to go diving without the benefit of adequate training (which may be no training at all or training at too low a level, e.g., only book training when the individual really needed private lessons) and accidents caused by a lack of training that resulted from inadequate course based instruction, e.g., panic and rushing to the surface with an embolism on the way as a result of a flooded mask.
  3. Lack of Experience: Again, we need to partition accidents that fall into this category, there is lack of experience, as in not having enough ocean experience to know how to judge and handle heavy surf or the diver was rusty, lacking sufficient recent experience. But both of these could ultimately be sorted simply into Poor Decision or perhaps partitioned, at least in part, into Lack of Training (e.g., how to judge your own experience and/or how to retool after a period of inactivity).
  4. Lack of Skills: Most people who Lack Skills usually do not know that they lack skills, so a Lack of Skills, while clearly a Poor Decision and often a Lack of Experience, more likely maps into a Lack of Training, as in either never trained to do that or inadequately trained to do that.

So I think that you can see how almost everything can be described as a Poor Decision and thus a human error, even though such a classification really sheds no light on the cause, it just makes an apology for the industry's failure(s).

Dan goes on to note: "Therefore, in addressing how accidents can be prevented, the onus is on the individual diver to ensure their training and skills are kept up to date and practiced regularly. Their equipment should be serviced by professionals and divers should ensure they are familiar with their own and their buddy’s gear configuration." That's kind of, "mom and apple pie," and I have no real problem with it in the general, but again, in the specific, it breaks down. How is the individual to, "ensure their training and skills are kept up to date and practiced regularly" when the new diver has no way to even know if their initial training was adequate and also has not idea of how to practice or what "regularly" means?

Dan also notes that, "Divers need to be aware of their personal level of experience and ability and not task-load or dive beyond their abilities." Again, how the diver to know? When you crap your pants staring down Baldy Chutes and know that you'd rather be back on the bunny slope ... then, as a skier, you know that you made a Poor Decision, when you got off the lift, you are out beyond your personal level of experience and ability; but ... when a diver gets kicked in the face, looses the regulator and has the mask flooded, chokes on some water, can't straighten things out and dies clawing for the surface, how was that diver to know, in advance, that this was going to happen? How was that diver to know that they were out beyond their personal level of experience and ability before the problem started? How are they to be prepared for this inevitability (at lest in terms of the start of the incident) by a video, a few pool session and a few ocean sessions? How is the diver to understand his or her personal responsibilities when their training all stressed how little can go wrong and how safe diving is? Or was it a Poor Decision, human error so to speak, to fall for that patter? Was it a Poor Decision, human error so to speak, to take such a course and not to seek out more thorough and complete training?

Dan concludes with the thought that, "If that human error could be eliminated, accidents and fatalities could be significantly reduced among divers." I'd stress that using Dan's logic, the instructor/course/LDS/agency/etc. could be absolved of almost all responsibility and liability for almost all accidents and fatalities, by definition.
 
Thanks Thal, you saved me from a lot of inadequate writing.



Bob
-------------------------------------------
A man's got to know his limitations.
Harry Callahan
 
Yeah, it's kind of a nothing story. The sea wasn't at fault...no surprise there :)

Don't have a heart attack and don't run out of air. Accidents could be reduced if you don't do those things :)

About all you can conclude from almost any dive accident report IMO is that you should dive more frequently (have more recent experience) and be more self-aware.
 

How is the individual to, "ensure their training and skills are kept up to date and practiced regularly" when the new diver has no way to even know if their initial training was adequate and also has not idea of how to practice or what "regularly" means?

A credible diving agency's instructors follow protocol and rules to ensure that certified divers were taught at least the minimum skills to keep themselves safe in conditions that do not exceed those in which they were trained. If the individual goes out of their way to find the cheapest course available, they will generally find 'the cheapest course available'. Nothing looks like a cheap suit quite... like a cheap suit. It is still a suit but it is cheap and the quality will show through.

I don't know about other agencies but PADI has a statement of Safe Diving Practices which divers should sign before doing any type of diving. In the statement (Section 2) it says "if diving conditions are worse than in those in which I am experienced, postpone diving or select an alternate site with better conditions." However divers continue to expect to do dives with extreme conditions and will select operators that will give it to them.


How was that diver to know that they were out beyond their personal level of experience and ability before the problem started?

Section 4: "Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognise that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed 6 months."

At the end of the day, this is just another piece of paper but if you read it through it makes a lot of sense.

All of the Statement's 10 points are valid but many divers really need to be more honest when signing it, and more operators need to be prepared to refuse divers that do not show the appropriate level of skill/experience/awareness etc.
 
It's easy to dismiss what Mr. Orr is saying, but I found a couple of very interesting statistics in the talk.

Although it's very intuitive that the first dive of a trip would be higher risk, 88% is an extremely high number. This immediately suggests to me that we might be able to reduce fatalities by ensuring that first dive is done under very controlled circumstances, and I wonder if the numbers are different at resorts that require a "checkout dive" before taking people to the "real" dive sites. Or if the number would be different if we looked at folks who either had recent (say, within a month) dive experience, or a recent refresher.

The second reaction I have is that 41% of fatalities involved running out of gas. Except in the extremely rare case of massive gear malfunction, this is ALWAYS due to the most egregious kind of human error -- a chain of mistakes that starts with poor planning and continues through poor monitoring and possibly bad judgment, to boot. This is where education in gas management could be a powerful intervention. I'm used to the reaction from instructors and divers alike, "Why do we need to know this stuff?" but perhaps increasing diver awareness of the gas requirements for deeper diving might result in a little increase in vigilance?

Despite Thal's dismissal of the article, I think it's important that people realize that the majority of lethal risk in diving is well within the capacity of the individual diver to reduce or negate. Better skills, better education, and better procedures WILL reduce lives lost; this is true is many other fields, and it's true here. The information is widely available, and the training can be found as well.
 
I thought it was not really honest to lump the out of air accidents into "human error" when the major training agencies don't require serious gas management expertise for OW or even AOW certification. If the same amount of training was provided for calculating turnaround pressures given various combinations of divers with various SAC/RMV's as for using decompression tables and staying within the NDL, perhaps the fatality rate for gas mangement failures would be more similar to that for DCS.
 
The other number that jumped out at me was that of the high percent of cardiac cases that appeared to ignore warning signs and apparently continued to dive...

What is of greater concern, he added, is that of those who died from cardiac causes, 60 per cent had signs or symptoms that they, or those who were with them, recognised as cardiac related.
 
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