This has been a poor year for diver deaths. I have just wrapped up a book called Staying Alive and it’s about risk management for divers… I started it because of a couple of regrettable incidents and as I finished it three months later, more deaths. The book is scheduled for launch next month from Amazon and CreateSpace. Here are my closing remarks.
Perception of risk changes over time. The more successful we are at beating the odds, the less risky we take our behavior to be; and of course, the opposite may be true. Too often, luck reinforces bad decisions and dilutes fear, and fear is surely part of the apparatus, our personal filter, for risk management. We each must understand that because someone surfaces from a dive with a smile on their face, it does not mean they follow a good risk management process or that their behavior is not risky. It is impossible to measure a negative. Vigilance is required.
I am sitting in my office wrapping up this project. There is snow on the ground outside and I will soon have to pack and get ready to fly to Europe and go to yet another interesting and very big dive show. Perhaps I should feel happy, but I do not: I am sad.
Yesterday evening I got news that a father and son (a boy of 15 who had earned no level of scuba certification at all) had both drowned in the Eagles Nest Cave, an advanced-level North Florida system considered a challenge to certified and experienced trimix cave divers. They were, according to family, testing out new gear the kid had been given for Christmas. What on earth were they thinking: what was the father thinking as he died? Last week, two more technical divers perished. One in the Red Sea and one in the caves of Mexico. I knew them both. One much better than the other but both were nice guys; both were experienced, and unlike the father/son combination who died in a spot where neither belonged, both of last week’s victims were what one would call careful divers.
Fatal dive accidents frequently have multiple and complex, often interconnected, root causes. While each accident has unique qualities about it – in part because of the individuals involved – most accidents can be characterized as a chain of small events that lead to disaster.
This chain of events very often starts with a minor challenge – a failure in communications, a broken strap – and one event meshes with a deficiency or mistake elsewhere and triggers something even more serious, and this in turn results in escalating calamities until the house of cards has fallen down completely. To stay on top of things, technical divers need to become pretty slick at recognizing problems early, preventing a chain reaction, and thereby avoiding a one-way ride to calamity. Often something as simple as calling a dive early, before anyone gets close to the edge, can change the outcome radically and turn a potentially nasty epiphany into a positive learning experience.
Gareth Lock, who was kind enough to write the foreword for this book, is a Royal Air Force officer with a background in risk analysis and management. In his writings and presentations, he shares with us a refreshingly analytical view of dive accidents.
He and I arrive at a similar destination via quite different analytical pathways. Based on his background in the military, he uses what he calls the HFACS Dive model (pronounced H – FACS-D). His analysis and methods are based on the Human Factors Analysis and Classification System framework developed by Dr. Douglas Wiegmann and Dr. Scott Shappell of the United States Navy to identify why accidents happen and how to reduce their impact and frequency. Gareth suggests that for a dive accident to occur, several contributing factors have to align. These factors may include organizational influence, unsafe supervision, a pre-condition for unsafe acts, and unsafe acts themselves.
I believe the factors, the triggers, that lead to deaths like the recent ones in a Florida cave, the Red Sea, and Mexico are more personal, more within our grasp. The eight triggers identified back in the 1990s: Attitude, Knowledge, Training, Gas Supply, Gas Toxicity, Exposure, Equipment and Operations, provide divers with a laundry list of potential dangers.
Gareth points out with some clarity, that people ‘get away’ with diving ‘successfully’ when there are errors at every level in his HFACS model: they simply did not align that day. “And that,” he tells us. “Reinforces bad decisions and creates diver complacency.”
One has to agree with him regardless of how or why you feel divers are dying so frequently. It seems that ignoring just one of the eight risk triggers may be enough to begin a series of events that end in death: it may take two or three, and a lucky diver may get away with ignoring four or five without an incident. Life is not fair that way.
Finally, Gareth reminds us: “It is easy to blame a person, when the system is actually at fault.”
I believe too that we are sometimes too quick to blame the individual and often do not trace the mistakes made back to their “systemic” roots, but sometimes all the fault does rest with one person. The system did its best and the best is all we can expect of anything outside of a nanny state. In some instances, the buck comes to a full stop up against the victim’s attitude, their ignorance, their lack of training, their history of flaunting the rules, their willingness to gamble with the odds.
Every day you and I, indeed the whole diving community, are faced with a dilemma: error of omission or error of commission. In cases where we know someone is pushing their luck, do we mind our own business, remain quiet and watch as they hurt themselves or their dive buddies; or do we speak out? If we are part of a system that Gareth and others say needs fixing, do we have the tools to carry out the repairs? Do we even know what to fix and where to start? Can we make a difference?
There’s a kid throwing starfish back into the sea as the tide recedes. A guy walks up and asks him what he’s up to. “Saving lives,” he explains. “The tide is going out and these starfish will die on the beach, so I’m throwing them back in.” The man laughs and tells the kid that the beach is miles long and that there are hundreds, probably thousands of stranded starfish. He tells the kid he can’t save them all. The kid stops what he’s doing, looks at the guy, looks up at the sky, and back out at the ocean. He bends down, picks up another starfish and throws it as far out to sea as he can. “Saved that one!”
My hope is that through all this effort, I may just get one person to think twice before starting a dive with a faulty oxygen cell, or breathing a gas that hasn’t been analyzed, or dismissing a buddy’s suggestion that today is not a good day to go diving or taking an unqualified diver to a trimix depth cave to test new gear. Help me save a starfish.