Investigation of diving accidents includes investigations into the causes of reportable incidents in professional diving and recreational diving accidents, usually when there is a fatality or litigation for gross negligence.
An investigation of some kind usually follows a fatal diving accident, or one in which litigation is expected. There may be several investigations with different agendas. If police are involved, they generally look for evidence of a crime. In the U.S., the United States Coast Guard will usually investigate if there is a death when diving from a vessel in coastal waters. Health and safety administration officials may investigate when the diver was injured or killed at work. When a death occurs during an organised recreational activity, the certification agency's insurers will usually send an investigator to look into possible liability issues. The investigation may occur almost immediately to some considerable time after the event. In most cases the body will have been recovered and resuscitation attempted, and in this process equipment is usually removed and may be damaged or lost, or the evidence compromised by handling. Witnesses may have dispersed, and equipment is often mishandled by the investigating authorities if they are unfamiliar with the equipment and store it improperly, which can destroy evidence and compromise findings.
Recreational diving accidents are usually relatively uncomplicated, but accidents involving an extended range environment or specialised equipment may require expertise beyond the experience of any one investigator. This is a particular issue when rebreather equipment is involved. Investigators who are not familiar with complex equipment may not know enough about the equipment to understand that they do not know enough.
For every incident in which someone is injured of killed, it has been estimated that a relatively large number of "near miss" incidents occur, which the diver manages well enough to avoid harm. Ideally these will be recorded, analysed for cause, reported, and the results made public, so that similar incidents can be avoided in the future.
Reasons for investigation
Professional diving accidents are usually investigated when a reportable injury occurs in terms of occupational health and safety legislation. The purpose is generally to allow avoidance of recurrences of the circumstances leading to the incident if practicable, and where relevant, to establish whether there was fault attributable to any involved party, which could lead to criminal or civil charges.
Accident investigation may help to identify the cause of a specific accident. If a pattern can be identified this may inform procedures and legislation to reduce the risk of the same pattern of accident recurring in the future. An investigation may identify shortcomings in training or procedures, or problems with equipment. Fatalities are often investigated as potential crimes until the cause of death has been identified. Insurance claims may rely on information from an investigation to establish whether the accident is covered by a policy. Occupational health and safety inspectors may investigate an occupational diving incident to identify whether regulations have been violated. Civil litigation for claimed damages can be more equitably decided when the circumstances leading to the injury have been identified. The ability to provide documentary evidence showing that correct procedure was followed can simplify the investigation and may lead to more accurate and reliable findings.
Equipment, procedures, organization, environment, individual factors and interactions between them are the sources of contributing and compounding events and conditions. Analysis of near accidents can be of great value to identify sources of error and allow planning to reduce or eliminate contributing and compounding conditions. A safety study estimated about a million shortcuts taken per fatal accident.
Accident investigations typically focus on the end event, and attempt to erect barriers to similar accidents, such as personal protection equipment, backup equipment or alarm systems. These are intended to prevent the recurrence of similar accidents, and are often effective in this limited goal. Accidents continue to occur because the majority of the contributing and compounding factors are not addressed. Human behavior and the systems in which people work are too complex to analyse all possible interactions. A more effective route to accident prevention is to reduce or mitigate the occurrence of human error by focusing on the contributing and compounding human factors that create an environment in which accidents are likely to occur.