“Thank [beep] for that! How lucky were we? We better not do that again. Don’t tell anyone though, we don’t want to look like amateurs...”
The problem with not letting people know what happened is two-fold. Firstly, others can’t learn from your mistakes; and secondly, the ‘authorities’ don’t obtain the evidence to show that there is a problem with whatever it was that went wrong.
Many of the more experienced divers lay criticism on the dive education agencies for not providing adequate training, and yet there is extremely limited hard evidence to show that there are problems with such things as lack of buoyancy control or gas management. There is, however, plenty of anecdotal evidence, when you speak to divers on boats or in the pub.
Everyone makes mistakes, even world-leading divers—those at the top of their game, the sort of people we aspire to be. So, if they have made mistakes, there is a very high probability that you or I have made similar mistakes, or errors, on a dive. Unfortunately, those who didn’t recognise the threat, or risk, until it is was too late are no longer here with us today taking part in a fantastic sport exploring our underwater world.
The following is a series of actual incidents that have ended with fatalities.
- Entering the water with O2 turned off on a rebreather; the diver died shortly afterwards.
Switching to 50% when at 36m depth and carrying on the dive down to below 50m because the diver hadn’t followed correct protocols for gas switching; the diver died after approximately an hour on the 50% bottle at depth.
Incorrectly labelling an emergency bailout cylinder so that it was placed at an incorrect depth leading to it being breathed at 3.2 ppO2; the diver had a seizure and died very shortly afterwards.
Task fixated in lifting an artefact, using backgas to inflate the liftbag as the original inflation cylinder had already been sent to the surface, and consequently running out of gas at depth, and then the diver did not use established protocols to use the dive buddy’s gas; the diver died following a rapid ascent to the surface.
Getting away with it
These are all simple mistakes and maybe the sort of thing that some of the readership might have done and ‘gotten away with’. If you did make a mistake like this, did you tell anyone or report it to the wider diving community through BSAC or another reporting system such DISMS?
Without knowing what prevalent problems are and why they occurred, it is very hard for training agencies to know how much emphasis to place on certain activities during training courses. It is also very hard for divers to accurately quantify the risks they are taking when they ‘break the rules’.
In addition, before you personally mitigate a risk (in risk management terms—tolerate, treat, transfer or terminate) you need to be able to identify it. However, from the commercial standpoint of the diving industry—that diving as an activity that needs to be promoted as a ‘safe’ sport in order to continue feeding new divers into the system—‘promoting’ these risks is not necessarily good for business.
Providing an environment where divers, instructors and those involved in management of diving and diver training operations can report honest mistakes and near misses is essential. This environment is one where it is accepted that we all make mistakes due to the limit of our experience, knowledge, training or the situations in which we are placed—an environment where the reporting of those mistakes, or near misses, is to be encouraged.
But at the same time, it is an environment where negligent or malicious behaviour is not condoned and allowed to continue. This environment is known as a ‘Just Culture’ environment and is part of the wider ‘Safety Culture’ that this sport should embrace if we are to reduce the number of injuries and fatalities occurring.
However, calling it a Safety Culture might have connotations of a ‘nanny state’, and as a consequence, the more experienced or independent divers may want to rebel against it. The discussion on a well-known internet forum following the Rebreather Forum 3.0 consensus position that checklists should be produced and used for closed circuit rebreathers to improve safety is a classic example of this.
The Just Culture aspect
A Safety Culture is not one entity, but rather is made up of a series of component ‘Culture’ parts. These include an Informed Culture, a Reporting Culture, a Learning Culture, a Just Culture, and finally, a Flexible Culture (see green box at right)
A Just Culture cannot exist on its own, but rather is interlinked with the other cultures. You cannot understand who has done what, when or why without an established reporting culture, and you won’t get those subjects to report if they think there isn’t an issue and don’t understand the risks that may occur if the situation conspires against one (informed culture).
The puzzle is not complete unless you have a Just Culture, as divers will not report an incident if they think they are going to be unjustly or inappropriately blamed for the incident or accident. Finally, a learning culture is required to know more about the risks that are out there—simplistically, gluing the pieces together.
Responsibility... personal responsibility
Looking at the tabloids, one could argue that society is now taking less personal responsibility for actions, appearing to look for someone to blame, rather than undertaking some sort of ‘personal risk assessment’— the so-called ‘Elf and Safety’ culture we now live in. Despite this, divers can be given training via a range of agencies and courses about how to undertake diving safely.
During that training, they should be taught to exercise caution as well as what the implications are of going beyond their trained limits, as they expand their experience and knowledge. Unfortunately, when a diver breaks these rules, and something goes wrong, there is a tendency to look for someone to blame for the incident, rather than understand why that diver made the mistakes they made.
This ‘blame culture’ means that companies are less willing to be involved in such a ‘hobby sport’—especially supporting closed-circuit rebreather (CCR)