Fatalities within Reporting Systems – Include Media Reporting or Not?

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One of the challenges in any reporting system is getting details of the incidents themselves so that others can learn from what happened and why things happened in the manner they did.  This headline (from 29 June 14) is a classic example, it publishes the results of the post-mortem, but it doesn’t ‘reveal what happened’ in a manner which allows others to learn.

There are a number of reasons why fatality reports are not discussed in public forums (legal concerns, pride, privacy, professional reputation) but then again these are the reports which make the (social) media. Sometimes there is good reporting (http://www.helsinkitimes.fi/lifestyle/11212-deep.html – 27 August 14, report into the double fatality in the Plura Cave System, Norway) but in the majority of cases, the media do not understand and are simply looking for a news story rather than to improve safety.

Something I am considering, but have not yet made a decision on, is whether to make the fatality reports public and provide media links but not provide any analysis; I already don’t provide public analysis on fatalities because of the lack of data available. I would also look to include any public information which arises at a later date e.g. Fatal Accident Inquiry or Coroner’s Inquest reports; these could be added by the community as a submitted report to an established incident.

The reason for considering this is because the number of fatalities is very small compared to the numbers of dives undertaken (approximately 1-2:100 000 dives) and therefore it is hard to de-identify fatality reports. Furthermore, once that level of de-identification takes place, what are the chances of learning anything from the incident?

However, I am also conscious that this goes against what DISMS was setup to be – an online, open but confidential reporting system.  Rest assured, public non-fatal reports would not have any media reports attached to them unless the reporter added them themselves – I do not want to compromise that confidentiality.

Therefore, I would be grateful for any feedback on the proposal because ultimately DISMS is a tool for the community and not for me, and I should be reacting to what would help safety in the wider context rather than just my views.

Thanks in advance

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3 responses to “Fatalities within Reporting Systems – Include Media Reporting or Not?

  1. Gareth – I hope all is going well! It would be great for the dive community of we could better understand the nature of the rare accidents that do occur. What caused them (root cause), what first aid would have made a difference and; most importantly, how they could be prevented in the first place. Good luck!

    • Steve, thanks.

      Unfortunately when we look at the way modern accident and incident analysis is developing, there is no such thing as a single root cause within sociotechnical systems (systems where humans/organisations interact with technical systems/equipment) because of the varied nature in which incidents can develop. In an article I have just written for X-Ray (due to be published in Nov) I show using a case study why you need detailed reports because of the multiple factors which are running in a parallel but are not an issue on themselves. e.g. suit inflate bottle empty, false confidence, dive likely to be cut short were all factors, but only when something else like a shut down needs to be completed does the hazard become very real and a potentially fatal situation arises.

      I believe there are three major things that need to happen if we are to improve diving safety: improved attitude to detailed reporting, improved attitudes to honest mistakes being made and stopping looking for someone or single thing to blame. We don’t have millions invested in recreational diving accident investigation but it is unlikely that causality would take a different tack to the established environments such as aviation or medicine where it has been shown that incidents do not have a single root cause.

  2. I would be in favour of seeing the media reports as although not always the most accurate in terms of terminology etc they do at least offer information that helps to build an overall picture.

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