Sad news, fatality on the Markgraf
Sad news, fatality on the Markgraf
Rememeber anything you read on the internet was probably written by some guy sitting at home in his underpants! Including this !!
Illegitimi non carborundum
The second in a few weeks. Very sad and I imagine I am not the only one worried that a TDF member is there at the mo. I hope they weren't involved but thoughts with all the loved ones and those that were involved
The sea, once it casts its spell, holds one in its net of wonder forever - Jacques Cousteau
Another sad loss and tragic event, but what I never see in this sport is incident analysis where people can learn from other mistakes or situations (not saying this was a mistake on anybodies part I have no more info than whats in the BBC article), but I fear this is the last we will hear of this, along with the many other incidents this year.
Having come from another extreme sport (skydiving), incidents there are discussed and analysed publicly, not for the purpose of manufacturer or user bashing, but purely to learn and improve the safety of the sport. Why is diving so closed when it comes to discussing these?
- No effective taxonomy to determine causality - most reporting systems focus on outcomes e.g. OOA, not 'how' or 'why'.
- No independent reporting system which has the support of all of the agencies.
- A poor just culture when it comes to talking about incidents
- People invest a massive amount of money and time into diving, they don't like to know they are fallible.
- A focus on outcomes rather than failed processes.
- The lack of accountability for the 'system' failures by organisations - training organisations have an 'air gap' between them and the client using the instructor to hold the risk.
- Very few people formally trained in incident analysis at a system-level rather than looking at the proximal cause.
- Risk is in the eye of the beholder, so how do you manage risk
- Fatalities are emergent events (multiple, apparently irrelevant, factors converge but are only apparent in hindsight.)
- The lack of resource (people, IT systems) to undertake data capture, analysis and reporting and create change.
- A fear that reporting leads to control over the sport
- Competition which is based around blaming other organisations for 'unsafe' practices.
Lots more on the blog here https://www.humanfactors.academy/p/blog and couple of videos here https://vimeo.com/user40492168, one from TekDiveUSA and one from the Long Beach Scuba Show.
How to solve it? Now therein lies the challenge!
www.imagesoflife.co.uk - Underwater Print Sales, Teaching and Stock Library
www.cognitas.org.uk - Improving Safety by Challenging Current Practices
www.divingincidents.org - Diving Incident and Safety Management System (DISMS) - 2014 Report here
“Set your expectations high; find men and women whose integrity and values you respect; get their agreement on a course of action; and give them your ultimate trust.”
“It is far better to be trusted and respected than it is to be liked.”
I guess that make sense, in some (maybe a lot) of circumstances, but certainly not all, just seems like any incident, even near misses, are quietly forgotten.
Any diving incident can be reported to the BSAC (governing body) incident recording system. Not just BSAC involved incidents. This is collated annually and reported on at the annual diving conference, this weekend. Trends may be identified and training influenced within the BSAC accordingly, other agencies are free to use the info provided.
Whilst this isn't perfect for any number of reasons , accuracy of reports for example, it is better than nothing and goes someway to answering your question.
I do agree that there is merit in discussing individual cases but there is an understandable reluctance to do this early and before an inquest that often takes months.
Evolution is great at solving problems. It's the methods that concern me.
As those two divers died in Scotland then Scottish Law prevails.
In Scotland there is no “Coroner” and no “inquest”.
It is the Procurator Fiscal.
He/she will decide if a FAI is required…… and for recreational diving deaths this is rarely done.
The PF may not be a diver but they will spend a fair chunk of time understanding what happened and if there any lessons to be learned.
They may well interview relevant parties (privately).
My thoughts are with the family and friends of those two divers.