Accident Analysis vs Emotions

[DandyDon]

Why don't we quote the Adjust Special Rules here...?

Special rules - Please Read

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The purpose of this forum is the promotion of safe diving through the examination and discussion of accidents and incidents; to find lessons we can apply to our own diving.
Accidents, and incidents that could easily have become accidents, can often be used to illustrate actions that lead to injury or death, and their discussion is essential to building lessons learned from which improved safety can flow. To foster the free exchange of information valuable to this process, the "manners" in this forum are much more tightly controlled than elsewhere on the board. In addition to the TOS:

(1) You may not release any names here, until after the names have appeared in the public domain (articles, news reports, sherrif's report etc.) The releasing report must be cited. Until such public release, the only name you may use in this forum is your own. New Change
(2) No flaming, name calling or otherwise attacking other posters. You may attack ideas; you may not attack people.
(3) No trolling.
(4) No "condolences to the family" here new change

It is important for us as a community to assess and discuss diving accidents and incidents as a means of preventing them. However, once emotions are involved intelligent discussion becomes next to impossible. Thot this was new, but it isn't If the moderators feel that the discussion is getting out of hand in any thread they may close or remove the thread, with or without notice.

 

[Rick Murchison]

Why don't we quote the Adjust Special Rules here...?

Since you've already done that Don, here are the old rules... so you can see what's changed

The purpose of this forum is the promotion of safe diving through accident analysis.
Accurate analysis of accidents and incidents that could easily have become accidents is essential to building lessons learned from which improved safety can flow. To foster the free exchange of information valuable to this process, the "manners" in this forum are much more tightly controlled than elsewhere on the board. In addition to the TOS:

(1) Events will be "scrubbed" of names. You may refer to articles or news releases already in the public domain, but 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.
(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.

It is important for us as a community to assess and discuss diving accidents and incidents as a means of preventing them. However, once emotions are involved intelligent discussion becomes next to impossible. If the moderators feel that the discussion is getting out of hand in any thread they may close or remove the thread, with or without notice.

Rick

 

[LAJim]

I've just come back from diving for a couple of days and need to catch up on all of this but in the interim there has been the accident on the Spiegel and I'm diving the Spiegel in two weeks. So, I have a highlighted need for real information, including general hazards on the site. Looked briefly at main Speigel accident post this morning - somewhat improved, but becase of the magnitude and interest huge number of posts with a small amount of info.

 

[LAJim]

After an hour of reading what I think I've learned is:

The divers had a lot of experience and certifications but I don't know which exactly or which agencies.
The divers were maybe wearing single tanks and had stages in a number of places on the wreck but maybe not down far where things went bad.
The divers had run a line but it broke.
The divers may not have had much of a dive plan.
They were in a real bad place down very deep and far.

That's not a lot of insight, and I bet I transcribed one or two of the above inaccurately. Curiously, I didn't get a whole lot off of TDS.

Jim

 

[HowardE]

The divers had run a line but it broke.

According to the Sun Sentinel - they did not

They didn't use a safety line they could follow to exit the wreck.

 

[LAJim]

So I know next to nothing after an hour - my point.

 

[HowardE]

So I know next to nothing after an hour - my point.

Nor does anyone else.

Here's the story from the Sun Sentinel - http://www.sun-sentinel.com/news/local/broward/sfl-cdivers18mar18,0,4219937.story

Apparently - someone who knew them is an SB'er and claims that they were in fact instructors.

 

[LAJim]

Its a remarkably good (newspaper) story on a dive accident. As such it highlights fundamental disagreements between the FL detective and the NJ dive boat operator - both citing the identical source.

One thing that is very clear is that this fatality does not reflect in any way on the safety of conventional recreational and even technical dives on the Spiegel Grove. The objectives were apparently beyond the limits that were intended for the wreck.

With fundamental disagreements (dive plan or no plan; enough gas or not enough gas; etc.) we're going to have to wait and see if a careful and knowledgible piece of investigative reporting comes of this. I hope we don't get a sensational and poorly sourced book - I imagine the proposals are already beeing faxed to publishers for the latter.

 

[HowardE]

Its a remarkably good (newspaper) story on a dive accident. As such it highlights fundamental disagreements between the FL detective and the NJ dive boat operator - both citing the identical source.

One thing that is very clear is that this fatality does not reflect in any way on the safety of conventional recreational and even technical dives on the Spiegel Grove. The objectives were apparently beyond the limits that were intended for the wreck.

With fundamental disagreements (dive plan or no plan; enough gas or not enough gas; etc.) we're going to have to wait and see if a careful and knowledgible piece of investigative reporting comes of this. I hope we don't get a sensational and poorly sourced book - I imagine the proposals are already beeing faxed to publishers for the latter.

I find it ironic, that according to news sources (that are not allowed to be named on SB) three other diver deaths occurred in the last week, and no uproar, not a peep even. Granted the Spiegel Grove is a huge tourist attraction / dive destination, but is the outcry even close to the same (to close the attraction - as was suggested by a few in the other thread) when a diver perishes in a cave, or other wreck? I think not.

 

[Blueskys4ever]

Swiss Cheese Model

From Wikipedia, the free encyclopedia

In the Swiss Cheese Model, individual weaknesses are modeled as holes in slices of Swiss cheese. They represent the imperfections in individual safeguards or defenses, which in the real world rarely approach the ideal of being completely proof against failure.

The Swiss Cheese model of accident causation is a model used in the risk analysis and risk management of human systems. It likens human systems to multiple slices of Swiss cheese, stacked together, side by side. It was originally propounded by British psychologist James T. Reason in 1990, and has since gained widespread acceptance and use in healthcare, in the aviation safety industry, and in emergency service organizations. It is sometimes called the cumulative act effect.
Reason hypothesizes that most accidents can be traced to one or more of four levels of failure:

Organizational influences
Unsafe supervision
Preconditions for unsafe acts
The unsafe acts themselves

In the Swiss Cheese model, an organization's defenses against failure are modeled as a series of barriers, represented as slices of Swiss cheese. The holes in the cheese slices represent individual weaknesses in individual parts of the system, and are continually varying in size and position in all slices. The system as a whole produces failures when all of the holes in each of the slices momentarily align, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through all of the holes in all of the defenses, leading to a failure.
The Swiss Cheese model includes, in the causal sequence of human failures that leads to an accident or an error, both active failures and latent failures. The former concept of active failures encompasses the unsafe acts that can be directly linked to an accident, such as (in the case of aircraft accidents) pilot errors. The latter concept of latent failures is particularly useful in the process of aircraft accident investigation, since it encourages the study of contributory factors in the system that may have lain dormant for a long time (days, weeks, or months) until they finally contributed to the accident. Latent failures span the first three levels of failure in Reason's model. Preconditions for unsafe acts include fatigued air crew or improper communications practices. Unsafe supervision encompasses such things as, for example, two inexperienced pilots being paired together and sent on a flight into known adverse weather at night. Organizational influences encompass such things as reduction in expenditure on pilot training in times of financial austerity.

Somewhat edited by me for brevity.