Blame vs Learning

- english incident analysis incident investigation incident reporting jenny lord just culture Oct 18, 2023

In last week's blog I asked myself if a student died after they’d been trained by me, would it be my fault? This week I got the call to say that a colleague hadn’t surfaced after a dive. It’s been a sobering reminder that this is real, that what we do has a degree of risk and that it takes more than we sometimes think about to survive in what is ultimately a hostile environment that’s incompatible with human life.

We at The Human Diver talk a lot about incident analysisinvestigation and a Just Culture. You can find a lot of blogs on here about all of those subjects. Sadly the reality that I’m watching play out in real time here is that there is mostly speculation, accusations and “shoulda, woulda, coulda”. Social media is the worst for this, with the uninformed throwing around the smallest morsel of information that instantly gets reported as gospel truth and analysed to microscopic levels.

We as a community have seen this play out over and over again, from local dive groups to big international ones. As humans, we’re curious. We all want to know what happened. One of the biggest problems we have in the dive industry is a lack of transparency when it comes to accidents and incidents. There is no international reporting system. There is no way to easily share details of accidents in a way we can learn from. So the void is filled by speculation and disinformation.  Already I’m reading comments online blaming my colleague for what happened, blaming his buddy, arguing about equipment, depths and procedures.

How can we stop this? This is the only sport I know of where this happens. Every other sport I’ve been involved in has either a far more supportive community or more robust analysis in place, often both. I understand that diving is different, it’s done in an environment where nobody might see what actually happens, and sometimes we can’t even recover the person in order to try and work it out. There is always a degree of guess work, not helped by the fact that people don’t always follow established procedures and often try to hide this fact.

The only way we as a community can change is by learning. That starts with being open about incidents and accidents. We need a reporting system, some way to share stories when we make mistakes, both large and small. DAN and BSAC do this to a degree but without it being detailed and accessible to all, as well as looking at behaviour, it’s not very useful. We as a culture need to change how we look at accidents. We will always be quick to judge but rather than condemning people on the internet, how about we start asking questions. The best one we can ask is “How did this make sense at the time?”. Because if someone has had an accident, it’s highly unlikely that they purposefully got in the water thinking “today I want to have an accident”.  Something has gone wrong to cause it. By asking how it made sense we’ll learn, and if we learn perhaps, just maybe, it’ll save one person’s life. I’m not saying that everyone wants the details of their loved ones' death poured over in minute detail. I appreciate that. But those who are willing to share shouldn’t be outright condemned. What do we gain from blaming a dead man? Learning from him however….working out why he did what he did, how it made sense at the time and trying our best to share this so that no one repeats it and makes the same mistake…Then that means it’s not a death in vain.

Many years ago when I had only just started diving I read the following on Scubaboard. I believe it applies just as much today as it did all those years ago.

If I should die while diving.

“If I should die while diving please do not hesitate to discuss the incident and assess every element with a view to furthering your understanding of how to enhance diver safety.

If I should die while diving, get the facts. They won't be readily available and will definitely not be correct as reported by the media. But get the facts as best you can.

If I should die while diving, understand, as I already do, that it will most likely involve fault on my part to some degree or another so do not hesitate to point that out.

If I should die while diving, some of the fault will probably belong to my buddy and that needs to be honestly assessed as well though I must admit this is one area where I hope that compassion will be in the mix.

If I should die while diving, there might be those who try to squelch discussion out of a misplaced notion of respect for the deceased, family and friends. They can say nice things about me at my funeral... but in the scuba community I want the incident discussed.

If I should die while diving, at least I didn't die in bed.”

Scubaboard- Uncle Pug

Jenny is a full-time technical diving instructor and safety diver. Prior to diving, she worked in outdoor education for 10 years teaching rock climbing, white water kayaking and canoeing, sailing, skiing, caving and cycling, among other sports. Her interest in team development started with outdoor education, using it as a tool to help people learn more about communication, planning and teamwork.

Since 2009 she has lived in Dahab, Egypt teaching SCUBA diving. She is now a technical instructor trainer for TDI, advanced trimix instructor, advanced mixed gas CCR diver and helitrox CCR instructor.

Jenny has supported a number of deep dives as part of H2O divers dive team and works as a safety diver in the media industry.

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