Accident Analysis vs Emotions

[ArcticDiver]

Rick:

I'm glad someone else is frustrated too. Folks who haven't been exposed to it don't really understand the process and the roles of everyone in the process. Either that or some imprecise thinking is leading to a lack of structure.

Maybe a recap from my point of view will help. Maybe not; but I'll give it a shot.

Someone dies while diving. At that point all we know for sure is that the person died. We don't know if it was an accident, a crime, or suicide. We don't know if it was due to a diver physiological failure, a mechanical failure, an act by someone else, or really anything.

In steps the Accident Investigator. That person's, or team's, job is to examine every detail of the situation they can. They look at the items in my prior post plus a lot more. After looking at everything they will write a report. That report is the Analysis for that accident/crime/suicide. They will itemize what they have been able to confirm, what they haven't been able to confirm, what they have been able to recreate and the conclusions they arrived at. If someone botched the investigation, or if they couldn't get a key piece of data they will include that in the report also. This is The Accident Analysis and is not an instantaneous thing by a long shot.

Then comes our role as divers. We can look at the Analysis for any lessons we can apply to our diving. We can use it for developing scenarios for training. We can do a lot of the What If type thing. What we are doing is Not analysis. It is making use of analysis.

So, yes, ScubaBoard can be a good method of communicating Accident Analysis to the rest of us for our use. No one should ever think that anything we do here can be remotely considered to be accident analysis. From what has been posted by the old timers I don't think that was ever even part of the intent.

Now as has been posted many times there is no opportunity to do even a mediocre job of accident analysis. That is a failure of the system and should be addressed by concerned citizens on each and every case.

 

[DandyDon]

In the time I have been here, I have seen one SB moderator lose his life diving. The outpouring of love and support was tremendous. And though it's been a long time, I don't remember anyone scrutinizing the available data to try to make sense of it and help others not make the same mistake. Other forums handled it differently. Perhaps it is just my poor, hazy memory.

It was discussed in A&I, and a probably cause was suggested from available information by one or more divers who knew him well. Then the thread was pulled, I do not remember a notice of any sort.

 

[lamont]

Rick:

I'm glad someone else is frustrated too. Folks who haven't been exposed to it don't really understand the process and the roles of everyone in the process. Either that or some imprecise thinking is leading to a lack of structure.

Maybe a recap from my point of view will help. Maybe not; but I'll give it a shot.

Someone dies while diving. At that point all we know for sure is that the person died. We don't know if it was an accident, a crime, or suicide. We don't know if it was due to a diver physiological failure, a mechanical failure, an act by someone else, or really anything.

In steps the Accident Investigator. [...snip...]

I was involved in a fatal dive accident awhile back and I think the Investigator for that accident must have forgotten to interview and debrief me...

Again, because there is no mythical Scuba Accident Investigation agency, there cannot be any Accident Analysis, since any discussion of a scuba accident is therefore speculation, we must never discuss any accident other than to offer condolences.

It'd be real nice if there *was* Accident Investigators, if there was the scuba equivalent of the FAA or NTSB, and if there was published accident analysis, but there isn't. In the absence of such an agency you and rick don't have a policy that deals with reality, but is wishing for the perfect world.

 

[Rick Murchison]

... The paractice of accident analysis is a professional discilpline.

Bingo!

Can we find an experienced diver who does this for a living (not scuba, generic accidents) to help us frame a protocol for analysis?

Uh, that would be me... (well, mostly, as I'm not actively doing it for money anymore)
Look at the "special rules" in the accident analysis forum - there's your framework and your protocol.
Is it followed? Not even remotely.
The protocol may as well not even be there - if you look through this thread you see some pretty passionate arguments that prove folks either haven't read the special rules, or don't understand what they've read, or just don't want any part of analysis - they want to do some CSI thingy... they want to understand... That's normal. That's human. That can be satisfying. And that's not bad.
But it isn't accident analysis.
When I first set it up (the AA forum) I tried to moderate there, but it was impossible. So I set up the fully moderated (posts must be pre-approved) forum. That was a flop because it got next to no participation.
All I can conclude is that there are so few of us here who actually want to do any real accident analysis that it isn't worth the time and effort. What folks really want is accident discussion and "investigation" in the Sherlock Holmes/CSI sense. They really want to know why the mishap occured, what people were thinking, who they are, they want to get to know them and to understand from a human perspective what happened. This isn't bad, it just isn't accident analysis.
Accident analysis is cold and impersonal and not what they want.
Let's take a look at the special rules, shall we?

(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.
In this thread I see all sorts of circumstances and reasons folks want to include names in their discussions. In accident analysis, names are irrelevant, and are never used. If you feel names are needed you're doing something other than accident analysis.

(2) No "blamestorming." Accident analysis does not "find fault" - it finds hazards - and how to reduce or eliminate them.
Accident analysis doesn't care whose fault it is, or whether an action was intentional, negligent, or unintentional. Accident analysis is interested in what actions were taken and what the result of the actions were, regardless of why. Why doesn't matter, only what happened. Woulda coulda shoulda doesn't matter, only what was actually done and what was actually the result. Hazards are identified and actions to ameliorate or eliminate them are formulated - this is the goal and the heart of accident analysis: identify the hazards and figure out how to handle them. We don't need to worry about fault or thought or liability to do that.

(3) No flaming, name calling or otherwise attacking other posters. You may attack ideas; you may not attack people.

(4) No trolling.
These two stand alone, don't you think?

(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.
Here's another one that flies in the face of human nature - we really want to know why someone did the things they did... "What was he thinking?" is a huge concern to us naturally, because we really do want to understand why things went the way they did.
But accident analysis doesn't get into that, because like names and personalities, it just isn't relevant to identifying what actually happened.

Bottom line, real accident analysis just isn't satisfying to most folks, and probably isn't what the vast majority here has in mind for the A&I forum.
Once again, for those folks who really are interested in the disciplined approach to safety that is accident analysis - if there's enough interest I'll start a fully moderated forum again. PM me if you're interested. So far I have one PM.
Rick

 

[Rick Murchison]

It'd be real nice if there *was* Accident Investigators, if there was the scuba equivalent of the FAA or NTSB,

AArrrgghhhh!
That would be your worst nightmare!
No!
No "I'm from the government and I'm here to help you" around Scuba.
NO!
Rick

 

[Rick Murchison]

I have long felt that the Scuba community could benefit from formal mishap/accident analysis. In aviation the process has been successful in the extreme, and I think applying the same protocol to Scuba mishaps could produce the same type "lessons learned" and save lives. When Scubaboard came along I thought it would be a good venue for such a project, and I still do.
How?
Well, I'm still (obviously) working on that.
Rick

 

[H2Andy]

Artic Diver, Rick:

i hear you guys. you are right.

however, there is no way in hell we can do actual accident analysis on ScubaBoard because we lack the access to the facts that an investigator has.

what you envision CAN NOT BY DEFINITION TAKE PLACE IN SCUBABOARD

so, we are left with two choices:

1. we dont' really talk about accidents and what might have happened (as we do now); or

2. we relax the rules to reflect that we are not engaging in Accident Analysis, even you two, given the information haze we work from, and allow more liberal "accident discussion" (if you will) so that people can talk about what happened to whom

ScubaBoard members are not official accident analysis investigators. stop acting like we are and holding us to those standards, because it's just killing the discussion.

 

[Rick Murchison]

Artic Diver, Rick:

i hear you guys. you are right.

however, there is no way in hell we can do actual accident analysis on ScubaBoard because we lack the access to the facts that an investigator has.

what you envision CAN NOT BY DEFINITION TAKE PLACE IN SCUBABOARD

so, we are left with two choices:

1. we dont' really talk about accidents and what might have happened (as we do now); or

2. we relax the rules to reflect that we are not engaging in Accident Analysis, even you two, given the information haze we work from, and allow more liberal "accident discussion" (if you will) so that people can talk about what happened to whom

ScubaBoard members are not official accident analysis investigators. stop acting like we are and holding us to those standards, because it's just killing the discussion.

Yep... I think I'll propose to the powers that be that we change the name of the AA forum to "Accident Discussions" and change the special rules to accomodate a more open discussion.
Rick

 

[paulwall]

We discuss Accidents on that forum to learn from them, and as tightly knit as the dive community can be - even when we do leave names out of threads as required, all too often the discussions touch personal nerves. I read all the threads there, post on several, and as far as I can tell - we're probably doing as well as we can on this.

What if we "abstract" away all of the personal identifiers (exact location, any reference to personalize it) and post it as a hypothetical scenario such as "Diver X, a male diver in his early 40's, with no previous medical history was diving in 50 ft of 70*water when separated from his buddy. Visibility was 25 ft, and there was a noticeable surge in the upper 15 ft of the column. After 45 minutes, a search was conducted where the diver was found with the reg in his mouth, 1000lbs of air in his tank, and his weight belt with 15lbs intact...(other "facts" as known listed here). Then state "this is all the information available" and let the possible scenarios leading to that incident be debated.

Then, we can play the "what if this happened, what if that happened" all we want without becoming too personal, and still get some lessons from the "hypothetical" incident. Leave the condolences to the other thread, and strip away the speculative posts.

I see similar "what would you do" posts in the Basic scuba discussions, and the near-misses areas. Kind of like the "I learned about Diving from That" section of the old Scuba Diver magazine.

 

[Doubles]

I find it very interesting that something so important is being commented on by so few. It's like the SB version of the usual suspects....

We do have more than one professional accident investigator on Scuba Board. If we had 2 forums - one a free-for-all like we have now with the usual moderation AND a real accident analysis forum that was heavily moderated WHY would anyone say no to having the heavily moderated forum. If you don't like that format or style, don't go there, go to the more open forum. But don't deny that forum to those who would go there.

If the heavily moderated forum dies from lack of use - then eat your popcorn and say I-told-you-so. Otherwise whats the harm in giving it a chance.

It would be nice to hear from some SB'ers who don't normally post - but who do lurk and read

Cheers

Steve