Root Causes: Some Accidents Are No Accident

Interesting flights and interesting dives provide an opportunity for post-event introspection; debriefing if you will.

Professionally, I am called upon to analyze fatalities and near-misses for the Navy and, occasionally, the Air Force. Personally, I spend even more time analyzing “what ifs” for my own activities.

For example, recently I was preparing a video of one of my more beautiful nighttime flights with a passenger, departing the coal-mining regions of Pennsylvania, heading south over the valleys and mountains of Appalachia as the early morning sun began to brighten our part of the world. Sunrise crop Editing that video gave me a chance to reflect on the pre-flight and in-flight decisions I made that day. There were many decisions to be made, and those decisions resulted in not only a safe flight, but a spectacular flight.

But like most things, there was also a risk, calculated, and weighted, and recalculated as conditions in flight and on the ground changed in the face of aggressive weather.

In very real ways, single pilot IFR (instrument flight rules) flight is akin to cave diving. They are both technically challenging, rewarding solo activities. However, you better be on your game, or else not play.

I was cave diving before cave diving was cool; before it was considered a technical diving specialty, before safety rules and high quality equipment was available. Trimix, scooters, and staged decompression were all decades in the future, and frankly the safety record at that time was atrocious. I am alive because I had the good sense to limit my penetration; “just a little” was enough of a sobering experience, about which I have previously written.

But this posting is not about moderation; it is a warning to those who would, for whatever reason, deliberately make bad decisions, one after the other. If after a chain of such deliberate misadventures, a fatality results, then I would say that fatality is no accident. It is a procedure; a flawed process of decision making with a more or less guaranteed fatal outcome.

Dr. Tom Iliffe, Texas A&M University at Galveston

Lest you lose interest in reading this post because you believe all cave divers are loonies, rest assured that could not be further from the truth. Where I work we have four very active cave divers, highly intelligent, experienced, diving deep breathing trimix (helium/nitrogen/oxygen) when necessary using scuba and rebreathers. They are safe divers who are on the cutting edge of diving research when they’re not diving for pleasure. In fact, two of them are the U.S Navy’s diving accident investigators, so they know all too well about underwater misadventures.

Friends met early in my career have been the cave explorers of the 70’s and 80’s; names you may know like Bill Gavin and John Zumrick. Another long-time friend from the Navy’s Scientist in the Sea Program, and of whom I am quite envious, is Dr. Tom Iliffe, a biologist constantly on the front edge of underwater cave biology. (My draft novel, Children of the Middle Waters, includes a story about his beloved Remipedes.)

All these cave divers have survived due to their sane and balanced approach to risk management; moderation in all things. But sadly, not all divers I’ve come to know, one way or the other, have been so sensible and measured.

One was a wonderfully gracious man, a Navy diver who had a hobby: free diving. He’d tell me how he enjoyed surprising divers in the main cave at Morrison Springs, Florida when he would swim up to them and wave, while wearing no breathing equipment at all except that with which he was born.

I’m sure they were shocked; I know I would be.

After a while, as he gained experience with this solo recreation, he began to confide in me, and ask me questions about events he’d experienced. He told me how pleasant it was sometimes when he would surface. I warned him about shallow water blackout, loss of consciousness on ascent, and explained the physical laws that made breath-hold diving so dangerous; at least in the manner in which he practiced it.

Morrison Springs, Florida. Photo licensed under Wikimedia Commons.

The last day I saw him alive, he once again came in for consultation, and told me about the euphoria he had experienced a few days before. I was of course extremely concerned and told him that what he described sounded like a near death experience. The next time he might not be lucky enough to survive, I told him. Later I heard more of that story; the previous weekend he had been found floating unconscious on the surface, but was revived.

Soon after that, this diver was again found, but this time his dive had proven fatal. His personal agenda for thrills exceeded all bounds of either training or common sense. And those thrills killed him.

The only solace I could find was that he wanted to share his experience and bravado, but he clearly was not interested in really hearing the truth, no matter how hard I worked to educate and dissuade him. While some might call this young man’s mental status as a perpetual death wish, I would argue that he never consciously thought he would die; at least not that way. Life was good, in his perspective, and I suspect he thought he was smart enough to make sure it continued that way.

Unfortunately when we were talking, we did not know just how close the end was.

Jackson Blue Spring, Marianna, Florida. Photo by Paul Clark, released under Creative Commons license.

The same was true I suspect for another well-liked diver who was the subject of a fatality report I helped write several years later. It was a rebreather fatality at Jackson Blue Spring in Marianna, Florida. The decedent was reportedly an experienced diver. I won’t belabor the story because the NEDU report is available on the internet (released by his family and available on the Rebreather Forum).

Nevertheless, the sequence of events leading to his demise involved a surprisingly long list of decision points which should have prevented the fatal dive from occurring. As each opportunity to change the course of events was reached, poor choices were made. In combination those choices led inexorably to his demise.

By now we know that even the U.S. Navy is not immune to poor decision trees. In fact, I would argue that wishful thinking is a common factor among people with intelligence and technical ability, and those with a “get it done” attitude. People who fix problems for a living are seemingly resistant to admitting that sometimes the bridge really is too far, and some problems are better fixed in the shop than in the field.

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Gareth Lock of Cranfield University, Bedfordshire, U.K. is currently collecting data on diving incidents through a questionnaire on “The Role of Human Factors in SCUBA Diving Incidents and Accidents”. Like me, he has both an aviation and diving background. Gareth is serious about trying to understand and reduce diving accidents. Links to a description of his work, and his questionnaire can be found here and here. If you are a diver, please consider contributing much needed information.

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