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Incident Report: Knowing When To Thumb The Dive

Conducting an incident and accident analysis after the event is relatively easy. Incident and accident prevention, or risk management, is much harder to do because we don’t know which of the thousands of possibilities are the relevant ones.

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By Gareth Lock

“Success is a lousy teacher if you get it right the first time.”

Conducting an incident and accident analysis after the event is relatively easy. Incident and accident prevention, or risk management, is much harder to do because we don’t know which of the thousands of possibilities are the relevant ones. This is especially true with diving. As such, we have to be conscious of our own limitations (skills and experience) and the pressures we will face. Not just time pressures, but also the social pressures we are under.

If someone invites you on a dive that looks exciting, a dive with other divers whom you respect and admire, and they have invited you along because of a certain skill set you have, such as surveying, photography or videography, it can be very hard to execute the right (which every diver has) to thumb the dive at any time for any reason. This is often even harder when we start to look at previous dives that turned out alright, because success is a lousy teacher—especially if you get it right the first time.

Photo by David Rhea.

“In 2015 I was asked to join a project as a documentation diver that would collect photos and video on a dive. We were a relatively large team of eight divers sectioned into four two-diver teams. My teammate on the dive was also the dive equipment manager for the project. At this point, I was still new to diving doubles and did not yet have a doubles wing of my own. Instead, I used one of the wings provided to me, not knowing that it had previously been scheduled to be serviced before this project began.

As we discussed the dive plan to a depth of 100 ft/30 m in a heavy current, it became clear to me that I would have to dive beyond my limits to make this mission a success due to the increased video and lighting equipment, and the scooter they were mounted on. Immediately I realized that I had a choice to make: scrub the mission or push forward and accept the risk associated with adding extra gear to a working dive. To me, adding the equipment wouldn’t be too difficult to manage, but I also did not think far enough ahead to unforeseen issues.

We ran through our pre-dive checklist, the GUE EDGE, on the surface. Everything was good to go. We entered the water as a team and descended fairly quickly to avoid the current throwing us off our bearings on our way to the dive site. To maximize the bottom time, I was diving double AL80s, with an AL80 stage bottle to breathe enroute to the target area. To maximize time in the area, I was using an exploration-sized scooter/DPV that had a DSLR camera, video lights, and housing mounted to the nose. I felt a bit overloaded and my heart was racing, but after we hit the water and submerged, I began to calm down. We scootered downward and forward, which was relaxing and exhilarating at the same time.

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This would be only my second scooter dive, my first with a camera mounted on it, and my first time managing a stage and switching regulators at depth. I felt confident in the scooter though, as my first ride went well and in this case it was helping to transport me and stabilize the camera. With the camera adding extra weight, the scooter was negative. This wasn’t really the issue I thought it would be. My confidence in using a stage was based on having filmed the required skills previously, with an instructor, and having watched it many times during editing process.

We stopped during the dive to check our bearings in about 80 ft/24 m of water. Being new to scooter diving, I thought it prudent to power it off while we were waiting to save battery life. At this point the scooter began sinking, so I decided to add a squirt of air into my wing to maintain neutral buoyancy. Shortly thereafter, the power inflator became stuck on as a result of corrosion built up after being in a salty environment for a year without proper maintenance.

My wing began to fill up and the inflator button was not responsive. Since this was my first experience of this, I did not immediately remember my training. However, muscle memory kicked in, and I first quickly signalled my teammate with a rapid light signal. He was looking right at me, so I figured he would be on his way over to help me, but he didn’t. I consequently began to manage the issue myself and reached back to dump the excess gas in the wing with my free left hand.

As I traced my hand back to find the dump valve to relieve excess gas from my wing, I found instead a stage bottle, which my mind said should not be there. I was able to get my hand around it and find the dongle to dump my full wing, but it continued to inflate. I tried to trigger the scooter to hold me at depth but I had turned it off. The thought process developed during training finally kicked in, and I unplugged the inflator hose. Luckily, the over-weighted DPV helped to hold me at depth long enough for me to manage this issue, and my buoyancy didn’t vary too much.

The rest of the dive was uneventful once I was stabilized in the water and had resolved the issue with the inflator hose.

Photo by Dickie Walls.

During the discussion after the dive, there were many lessons my team and I identified and subsequently learned:

  • My teammate never saw me signal, nor did he ever notice I was having trouble, highlighting the importance to both of us of situational awareness.
  • A quick tap of the inflator button to check for proper function during a pre-dive check is not adequate.
  • Overloading oneself with new gear, while easy enough to manage with good skills and the right mindset, can quickly become a serious inhibiting factor in an unexpected situation or when an emergency is encountered.
  • Poorly maintained gear, due to either an act of laziness, forgetfulness, or of being too burdened with other tasks to get the job completed, can cause problems!
  • The dive plan that revolved around me as the camera operator had requirements beyond my training or experience level.
  • I made a repeated series of misguided actions, like turning off the scooter or forgetting I had to get my hand around a stage, instead of immediately just disconnecting my power inflator hose. I had never had to do that before, but during the dive I remembered I saw my fundamentals instructor posing the question to us during class four years prior.

So the situation is all very clear to me now, and I can see how it could have been worse, but also how it could have been handled better. I learned from this experience. I now know better what my limits are and how I could misperceive the skills required versus my current skill levels. That day I became a better, safer diver because my mindset changed. I have continued to train and dive with a new mindset that will hopefully lead to me handling issues in a more intelligent way as I continue forward on project dives and into the beautiful world of cave diving.”


Photo by Andreas Hagberg.

Comments: The subject diver picked up many of the issues they personally faced. These included overconfidence, inadequate technical skills, assumptions, hubris, decision-making, and some of the factors associated with their teammate (I’ll comment on this in a moment). But there are also factors which were missed covering the wider project. Specifically, the team had an expectation that someone with limited experience would be able to pick up a complex task and manage it, even if something went wrong.

Executing this dive when everything was 100% perfect wouldn’t appear to have been an issue, but how often do we consider the “what ifs”—you can’t rely on everything being 100% perfect 100% of the time. As project leaders, how often do we consider the pressures to conform socially, which makes it harder for inexperienced but massively keen divers to say “this isn’t right” and thumb the dive or at least raise some concerns? The greater the social kudos associated with the project, the harder it is to say no.

The comment about the situational awareness of the teammate is also worthy of note because situational awareness is based on building up knowledge using your senses. Just because something is in a teammate’s field of view it doesn’t mean that they have seen it. The diver that had the problem had the responsibility to ensure that the communication loop with their teammate had been closed by signalling until the teammate responded, indicating that they were cognisant that the diver had an immediate problem.

Innovation and exploration cannot happen if you don’t push the limits. By definition, you are stepping outside the experience zone. This also means that the margins for error are greatly reduced and therefore there is a need to get everything as close to 100% perfect as possible. This requirement to “fail safely” means identifying interactions within the system that might cause you and your team problems, e.g., heavyweight scooter, additional stage, lack of practice, and what you can do to mitigate those risks from materializing.

The opportunity to learn directly from adverse events can be hard because diving is pretty safe (in terms of numbers). For that to happen, there needs to be a “just culture”. A just culture isn’t a blame-free culture, but one which recognizes that we are all human, that we all make mistakes, and that grossly negligent behaviors will not be tolerated.

With a just culture in place, we can learn from others by having context-rich stories like the one above, which look at not only the technical aspects (scooter weighting, OPV, servicing of the inflator) but also the human elements (skills practice, social pressures, inexperience, assumptions, hubris) so that we are better prepared to deal with the uncertainties and fastballs that come our way. Learn from your mistakes; better still, learn from someone else’s.

To learn more about “just culture” and what it can do for your team, follow the link to this free Human Diver webinar. Read Gareth’s post Mental Models to learn more about how our subconscious actions effect our safety.

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Gareth Lock is an OC and CCR technical diver with the personal goal of improving divingsafety and diver performance by enhancing the knowledge, skills, and attitudes towards human factors in diving. Although based in the UK, he runs training and development courses across the globe as well as via his online portal https://www.thehumandiver.com.He is the Director of Risk Management for GUE and has been involved with the organization since 2006 when he completed his Fundamentals class.

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Why I Became a GUE Instructor

Jon Kieren had been an experienced tech diver and instructor for years when, curious, he took a Global Underwater Explorers’ Fundamentals class, a prerequisite to GUE’s technical and cave training. Soon, he didn’t just want to be a GUE diver. He wanted to be a GUE instructor. Kieren writes about the draw of GUE and why he started over with a new agency.

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by Jon Kieren. Photos courtesy of SJ Alice Bennett.

I’ve had the pleasure of working in pretty much every aspect of the diving industry over the past 15 years or so. I’ve been an instructor and boat captain in the Caribbean, worked in the training department of a large training agency, served as a consultant for equipment manufacturers, and traveled all over the world teaching as a full-time cave and technical instructor trainer. Many would have said I’d reached the highest levels in the diving industry. 

So when I decided to start all over from scratch to become a Global Underwater Explorers (GUE) instructor, many of my friends, peers, and students scratched their head a bit and wondered why I would want to invest so much time, energy, and money to teach things I had been capable of teaching for years with other agencies. The answer was I wanted to commit to excellence. “Can’t you do that by teaching for other agencies?” they would ask. Not really.

Over the years, I had become quite frustrated with almost every aspect of the dive industry. Low-quality instruction, lack of accountability from agencies in accidents and quality assurance, manufacturers releasing equipment that created more problems than it solved, and dive shops and instructors at all levels racing to the bottom in terms of quality — all of it was making my blood boil. When I “saw the light,” it was refreshing, inspirational, and a huge relief. I finally found an answer to many of the issues I had been banging my head against the wall trying to solve for years. Here’s how it went down.

In 2016, I left my job in the training department of a large agency after five years of frustration. I realized I could make a larger impact on the industry working with one or two students or instructor candidates at a time. I moved from south Florida to north Florida’s “cave country” to teach full-time as an independent instructor. It was a bit scary to not have a guaranteed paycheck, but I was determined to make it work. I was hungry to improve as an instructor and knew I could do better. The problem was, after working at the highest levels with some of the biggest names in the industry, I didn’t really know where to turn. 

Enter Mark Messersmith. He’s a GUE board director, instructor evaluator, chief operating officer of dive equipment manufacturer Halcyon, and one of the nicest guys around. I had gotten to know Mark a little bit over the years, and always appreciated his laidback and super supportive demeanor. When I approached him about GUE training, he asked, “Why?” Knowing my background, of course he knew the answer, but I think he wanted to hear it from me. 

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Fundamentals: Where the Fog First Lifted

I first started down the technical diving path when I was working in the Caribbean as an open water instructor and boat captain, and I came across GUE in my research. I was immediately put off by the standardization and team-diving philosophy, and decided other agencies would be a better fit for me. Of course I didn’t know what I didn’t know, but my thought was, “There can’t be just one way to do EVERYTHING.” Plus, I really enjoyed solo diving at the time. After moving through the ranks over the years and working with hundreds of technical, rebreather, and cave students, I had the opportunity to work with several GUE-trained divers. Most of them had only taken Fundamentals, the prerequisite to GUE’s technical and cave training courses, but two things were consistent with all of those students: The classes were easier to teach, and they were way more fun. We would be able to start cave or tech diving straight out of the gate and not need to spend three or four days on basic skills. I wanted to know what GUE’s secret was to create such solid and consistent divers, and that’s when I approached Mark.

To answer his question, I was honest and told him I wanted to steal as much as I could from the Fundamentals course to incorporate into my classes. He just smiled through his mustache and said, “OK.” We scheduled a class, and I got to work watching all of the skills videos and practicing on my own in order to prepare. To say that I was nervous when class started was an understatement. I think I hid it pretty well, but what if I didn’t meet the highest standard for Fundamentals and get GUE’s coveted tech pass? What would that say about me as an instructor? Mark’s casual style put me at ease as we began, and I was able to focus. When Mark got to the third slide of the first lecture, it was like the fog had lifted and I could see everything clearly for the first time. I knew the trajectory of my career had just shifted and I’d be starting all over. “This is going to be expensive,” I thought.

So what’s on that slide? A simple statement that was the answer to all of my struggles: “End the disconnect between training and passion.” As Mark explained the issues in the dive industry, of which I was all too aware, he also explained how GUE addresses those issues. From the top down, GUE’s board of directors members and instructors are passionate divers and explorers, no exceptions. This changed everything for me. One of my biggest frustrations was recognizing that at the very top of the industry (senior managers of the agencies), almost nobody was an active diver. Presidents and VPs were diving once a year for social media posts to create an illusion they were still active and passionate—many of them with very limited teaching experience and making decisions on standards at the highest levels of technical, cave, and rebreather training when they had only been in a cave once or dove a semi-closed rebreather a couple of times back in the 90s. 

This lack of passion filters down through the industry. It’s amazing how many instructors (technical, cave and rebreather included) refuse to get in the water if they aren’t being paid. Even with my limited experience at the time, when I went to work for the agency, I would have my head in my hands thinking, “You have no idea what you’re talking about,” when sitting in on big meetings as industry heads for all of the agencies were in my opinion focused more on how to keep standards low and profits high rather than on safety and quality. 

A Commitment to Excellence

But now, staring at this slide, we discussed the ways GUE is focused on keeping quality at the highest level and inspiring divers to be passionate, competent, and capable of incredible conservation and exploration efforts. We discussed the global GUE community and all of the remarkable things they accomplish. It was so clearly the answer to everything.

I didn’t just want to be a Fundamentals diver. I wanted to be a GUE instructor. As I started on the path, I started to really realize why “Commit to Excellence” is printed on the back of our t-shirts. I was pushed harder than I had ever been in the past, with support and encouragement. The goal was always to improve, no matter what we were doing: from parking our cars at the dive sites to be courteous and leave room for others, to maintaining perfect stability in extremely task-loading situations, and developing the best instructional and evaluation techniques. There was never a time in any of my classes where I was told, “Good job.” It was always, “Good job, but here’s how we can make it better.”

My Tech 1 (and later Tech 2) instructor, Guy Shockey, made a statement that I remember every day. He explained that he chooses to be a GUE instructor because when he wakes up in the morning and gets ready to teach a class, he knows without a doubt that he has the capacity and resources to teach the best class available. So when I’m on my way to the shop or dive site to meet my students in the morning, I keep that in the back of my mind. I have the capacity and resources to teach the best class available. It not only gives me confidence, but keeps me honest. There are no excuses and no room for shortcuts. Commit to excellence. 

We are held to that standard of excellence through several mechanisms. We have strict annual renewal requirements to ensure we are actively diving and exploring so that students are learning from someone still passionate about what they are teaching. These requirements go far beyond what is typical in the industry, and we are actually monitored for meeting them.

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Staying Current (And Competent)

Most agencies have some form of “currency” recommendation, meaning you’re supposed to teach or assist a class every few years. However, there’s no oversight to ensure instructors are meeting this requirement. There’s loads of instructors out there (tech instructors and instructor trainers included) who haven’t taught a class in five-plus years. There’s nothing stopping these instructors from going out and teaching a class at their highest level. Sure, if something terrible happens, the agency and insurance company will likely drop the instructor, showing that they violated a standard by not remaining current. But at that point, it’s already too late. Students pay the price. Even if there isn’t an accident in training, it’s very likely that students will not have received adequate training and will be more at risk in their post-training diving activities.

GUE instructors need to show dive logs verifying we have conducted at least 25 non-training dives each year, half of which need to be at or above their highest teaching level. This ensures that when you sign up for a GUE class, you can be sure the instructor in front of you is still active, current, and passionate about what they are teaching you. 

All GUE instructors, instructor trainers, and instructor examiners are required to be re-evaluated at their highest teaching level every four years. Nobody is exempt from this rule, as it means that we are consistently ensuring everyone is teaching the same things, to the same standards, without drift. 

Scuba diving is a physically taxing activity, and the more aggressive the dive, the more physically fit the diver should be. Even on fairly benign dives, you never know when the current or seas might pick up, or when a failure could result in extended decompression times. We believe that having physical fitness requirements that are consistent with diving goals is extremely important. No smoking allowed for any GUE diver or instructor, and we require swim tests at every level of training. 

Instructors have to meet pretty stringent fitness requirements each year. We have to be medically evaluated for fitness to dive, maintain a low Body Mass Index (BMI), conduct timed swims and diver tows, stair climbs and equipment carries over long distances, all of which verify our ability to assist our students in emergencies. This is surprisingly absent from other agency’s renewal requirements. There are lines in the renewal agreement about being fit to dive, but there’s no oversight, and they don’t even require a medical exam.

We also have a 100% quality assurance process, meaning every student completes a quality control form. This is not only so our QC director can identify any drift from the standards or issues with our conduct in class, but also to help provide feedback on how we can improve the training we offer. We encourage our students not to just tell us what we did well, but treat us how we treat them in the debriefings and include areas we can better support their growth, because there’s always some room for improvement.

I don’t mention all of the renewal requirements as a flex, but rather to show that it takes a significant investment for GUE instructors to remain in current teaching status. Someone who isn’t committed simply won’t remain current. It was a huge draw for me, as I had seen how the minimal standards typical in the dive industry contribute to the disconnect.

For me, as an instructor, the benefits of GUE go beyond the high-quality training, standardization, and community. The opportunity to work toward ending the disconnect between training and passion as well as the continuous commitment to excellence are what keep me motivated. Not a year has gone by since my Fundamentals course that I haven’t seen significant growth as an instructor, and I don’t see that changing until I hang up my fins.

DIVE DEEPER

InDEPTH: The Economics of Being a Tech Diving Instructor by Darcy Kieran

Other stories by Jon Kieren:

InDEPTH: I Trained “Doc Deep” by Jon Kieren

InDEPTH: SUMP POTION #9 by Jon Kieren

InDEPTH: Grokking The FATHOM CCR: My Dive into the Nuts & Bolts with the Inventor by Jon Kieren

Jon Kieren is a cave, technical, and CCR instructor/instructor trainer who has dedicated his 13-year career to improving dive training. As an active TDI, IANTD, NSS-CDS, and GUE Instructor and former training director and training advisory panel member for TDI, he has vast experience working with divers and instructors at all levels, but his main professional focus resides in the caves. In his own personal diving, Jon’s true passions are deep, extended range cave dives, as well as working with photographers to bring back images of his favorite places to share with the world. 

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