The Power of One…

PowerofOneThere are a multitude of examples of accidents where the major causal factor has been the down to the inability of a more junior operator to question what the more senior person or persons have done when they really believe that the more senior is/are going to make a mistake.  Three examples covering medicine and aviation are given below but this learning can easily be applied to sport SCUBA diving.

“John Pickles, an ENT surgeon and former medical director of Luton and Dunstable Hospital NHS Foundation Trust, told me that usually when an operation is carried out on the wrong part of the body (a class of error known as “wrong-site surgery”), there is at least one person in the room who knows or suspects a mistake is being made. He recalled the case of a patient in South Wales who had the wrong kidney removed. A (female) medical student had pointed out the impending error but the two (male) surgeons ignored her and carried on. The patient, who was 70 years old, was left with one diseased kidney, and died six weeks later. In other cases nobody spoke up at all.”
– http://www.newstatesman.com/2014/05/how-mistakes-can-save-lives

On 27 March 1977, a KLM B747-200 commenced its daylight take off at Los Rodeos airport, Tenerife in very poor visibility, recorded as 300 metres three minutes earlier, after receiving only a departure clearance and continuing the take off roll even after ATC advised “standby for take off”.  Collision with a Pan American Airways Boeing 747-100 which was taxiing on the runway in accordance with its ATC clearance issued on the same radio frequency. All 248 people on board the KLM aircraft died and only 61 of the 396 people on board the Pan American aircraft survived.”  Despite ‘shallow’ questioning by the flight engineer and the co-pilot, the captain initiated the take-off roll without clearance. “The fundamental cause of this accident was the fact that the K.L.M captain:
1.Took off without clearance.
2.Did not obey the “stand by for take-off” from the tower.
3.Did not interrupt take-off when Pan Am reported that they were still on the runway.
4.In reply to the flight engineer’s query as to whether the Pan Am aeroplane had already left the runway, replied emphatically in the affirmative.”

– http://www.skybrary.aero/index.php/B742_/_B741,_Los_Rodeos_Tenerife,_1977_(RI_AGC_WX)

UA 173 experienced a similar landing gear light problem. The experienced captain noticed that the plane’s nose gear light failed to turn green to indicate it was properly deployed. With the control tower’s permission, the pilot circled the plane and ran through his checklists to troubleshoot the problem, but the nose gear light stayed red. While circling, the first officer and flight engineer told the pilot that the plane was running low on fuel. The pilot apparently ignored the warnings. Post-crash analysis revealed that the green light bulb for the nose gear had simply burned out; the landing gear had been deployed the entire time. The NTSB found that the crash was caused by the captain’s failure to accept input from junior crew members and a lack of assertiveness by the flight engineer.
– http://en.wikipedia.org/wiki/United_Airlines_Flight_173

But authority gradient isn’t just limited to areas where there are formal hierarchical situations, they occur whenever there is a difference in experience or knowledge and those in the senior position in diving (instructor, more experienced buddy) need to be aware of this and potentially change their behaviours accordingly.

The following two real diving examples highlight where failures have occurred.

An OW instructor has two students (divers 1&2) on an AOW course for the week but this particular dive is a guided dive to 35-40m. Along for the dive is an Advanced Nitrox and Deco Procedures qualified diver (diver 3). The dive takes place and one of the OW divers gets very narc’d at 38m. After an uneventful dive, all four ascend and conduct some mandatory decompression stops (not briefed or planned for). On surfacing diver 3 asks divers 1&2 if they had additional insurance like DAN diving insurance to cover them beyond normal holiday insurance*. They only had holiday insurance assuming that the instructor’s insurance would cover them even though this wasn’t a recognised deep dive on the AOW course.  Diver 3 knew that what was going on during the dive was wrong but didn’t thumb the dive because they trusted the instructor. They also admitted an abdication of responsibility as there was a more senior diver (instructor) present. Diver 3 decided never to use this dive centre after this and a couple of other incidents.

An instructor was teaching a decompression course and one of the requirements was for one student to manage the decompression for all of the divers on this dive.  After 15mins of stops at the shallowest stop, the instructor signalled to the students that their decompression obligation was clear and asked the lead student what they wanted to do. The student decided to ascend which ended up with two of the three divers have symptoms of DCI.  The instructor hadn’t realised that effect that his position would have on the student’s decision making process and has subsequently changed his behaviours.

The easy answer is normally, “well the student should know and should question what is going on”. Consider you are now a baby student in some domain and you have the head of the training agency, or the most senior Course Director teaching you the course, and they start to do something which you know is wrong, how easy would it be to stand up and say ‘Excuse me, but is that correct?’ or in the case of being underwater, being able to thumb a dive and discuss it on the surface?

Unless you (as the senior person, or the organisation you work for) have created the environment from the outset where ANYONE can challenge you for ANY reason then the errors will promulgate through. In aviation terms this is known as Crew Resource Management (CRM) CAP 720 (2002).

If you would like me to visit your club or organisation to discuss improving diving safety by learning from other environments, please contact me.

Safe diving…

*The reason for asking this question was because it was shortly after a British diver had to remortgage his house after exceeding the depth of his holiday cover insurance and had to pay for the chamber recompression treatment himself as his insurance was limited to 30m.

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