Accident because outboard engine caught fire: Part1, by lumba lumba diving centre

[LumbaLumba]

ACCIDENT AND INJURIES BECAUSE OUTBOARD ENGINE CAUGHT FIRE: REPLY BY LUMBA LUMBA DIVING CENTRE

Reply to the following threads:
Singapore Scuba Diving Forum » Scuba Diving Destinations » South East Asia » Lumba Lumba – Pulau Weh – Serious Safety Concerns – and a dangerous incident
http://www.scubaboard.com/forums/ac...rious-safety-concerns-dangerous-incident.html
http://www.scubaboard.com/forums/scuba-related-court-cases/382738-danger-lumba-lumba-palau-weh.html
http://www.scubaboard.com/forums/indonesia/348920-pulau-weh-resort-3.html
Lumba Lumba – Pulau Weh – Serious Safety Concerns – and a dangerous incident
Forums plongée Plongeur.com - Lumba Lumba Resort

Written by Ton Egbers, Operational Director and Co-owner.

First of all, before anything else:

Of course we were also terribly shocked to hear about one of our outboard engines catching fire, our boat driver getting cuts and burns and Dorien, our diving guest from Belgium getting hit by the boat and her wetsuit caught in the propeller plus a cut in her foot after that!!! And just as any other diver having made safety stops with propellers going overhead, body still, but imagination running, we fully realize it could have been much worse. So we are also extremely glad Dorien and Arul’s injuries only needed limited medical care, healed all well in two, three weeks or so in both their cases, and apart from some minor scarring that will remain, has not lead to any lasting disability for either of them. Dorien’s own story regarding this you can find elsewhere on this thread/the web.

DELAY IN REPLY

That we were shocked, but that it took us so long to give a statement ourselves, was not because we didn’t care. Having first set up in ’98, then built our own centre in ’02, no business during 03’-04’ because of Aceh’s conflict, and then rebuilt after the tsunami: Of course we do!

But first there was a practical and later a more principal reason:

At the time the accident happened we were on a trip back to the Netherlands. And very unfortunately we weren’t notified immediately, despite the importance of the matter. So we were actually extra shocked when we got the bad news, as it was only first through DAN Asia Pacific that we were approached on Friday 20 May about the accident, which was already over 3 weeks after it had happened! So NO ONE had told us about it yet, including none of our crew. That our crew did not mention it may seem bad to many, but actually there's quite a number of positive reasons for it, especially the recovery of the Belgium diver and her appreciation of our care. To explain more of their valid reasons, would talk too long at this stage. But on a positive note from us about our own Indonesian employees coordinating matters when we are away, at least it shows that they are willing to accept responsibility at high level themselves.

Now maybe because we knew too late and could not assess ourselves to what extend ALL people visiting Lumba Lumba at that time were shocked or traumatized by the accident, it took too long for us to contact the writer of the report or any others of his group about it. Assuming the best intentions of most people, and estimating the date of DAN contacting us, and the postings of Albion hitting the web, he may have actually waited, hoping for a direct personal reaction from us first before finally pushing the "report" button. But just like some other bad coincidences regarding this accident, that apparently wasn't meant to happen, we didn’t know about it yet…

Then after we heard, you can see that it still took us quite some time to come up with this reply as well. Again, that wasn’t because we didn’t care, no precisely the opposite, because we DO care: We know it takes time for a thorough reply. Of course we could just quickly say something at that stage, but there’s already enough yes/no, is/is not, like/dislike, I assume, probably, maybe etc, etc, discussions on many forums, and often blurring the main thread.

So we needed to know more of what happened and what followed, of which knowing Dorien’s and Arul’s condition clearly stood above all. When we heard Dorien was doing fine and when we got our first crew reports about the accident including hearing Arul was doing fine as well, we immediately reported back to DAN on Monday 23 May with our initial findings. Then after that we had our last days in Holland, be in transit on the way back, and it couldn’t be earlier than last Friday morning, 3 June (no fishing/dive boats going out on Friday morning in Aceh), before we could do an elaborate staff meeting as a first session for fact finding and preliminary analysis.

So now this has taken place, I think I can finally give a response that gives as much of a complete view on things as possible. That’s with the status of information as I have it now.

Thank you for bearing with me this far already, but because quite some comments of contributors expressed doubt (or worse) about our emotional and/or professional commitment, I did feel it necessary to underline that we DO care! How can people assume otherwise, it’s our own business and 20 families from the island’s local villages directly depend on it for a living, plus 2 young teenage boys that we foster…

BIAS

Now when covering all details of the story, of course it’s a representation of things AS I SEE IT. But very importantly, it’s also what my wife Marjan, and Din, our main Indonesian executive all agree on. Sure, that’s still very subjective. But it can’t be otherwise. So I think it is most honest to highlight 3 aspects of our own bias which highly influence our (dive) operating policies:

- Knowing rules, regulations and guidelines is important. But knowing them to the letter is not what matters: it’s understanding what they are meant for.

Yes, I’m fully aware that this is quite a tricky thing to say at this stage, when we’re discussing smoking issues and the accident of an engine fire, but hey, we can only save the world one beer at a time… Now please don’t immediately start blogging me to death at this stage, it’s not my intention to make fun of Albion’s own motto at all. Totally on the contrary, I’m honestly trying to relate here, because that is of course what I meant when I indicated that maybe we’re not totally at the end of the world, but certainly at one of Indonesia’s ends. And most men here still smoke (BTW, Arul, the senior boatdriver is a non-smoker), a lot of our customers still smoke, so yes, we can only change the world with one smoker quitting at a time, and others not to starting either. Just a pity I didn’t understand his way of saying things that stressy evening before I left to Holland…

(Marjan and me quit 10 years ago, but clearly haven’t become more Catholic than the Pope)

But let’s not get ahead of things here. So though risky, I still state the line above, as Marjan and me have mixed dive educational roots, both CMAS and PADI, both club and commercial, and this is strongly determining our diving policies.

- Doing It Right can also be done left handed

What we mean here, is that there’s often not just one way of doing things, in fact, usually there are numerous ways of doing things. For example, a diver gears up and you don’t know anything about him (or her), and he puts his weigh belt on in such a way that it’s “the other way around”. Then instead of pointing out that the diver is putting his weight belt on the wrong way (suggesting you know the right way*), we think a better approach could be: “I noticed you put on your weight belt the other way around than usual, you have any special reason for it?”. It doesn’t have to be as obvious as a one armed/handed diver (BTW, we had one becoming PADI DM with us), but it can be an experienced left handed solo diver for example. Or yes, probably it’s just “Oops, didn’t pay attention, yes wrong way around, thank you”….

So seeing someone do something differently than you assume to be “the rule”, does not mean that another person is necessarily doing it wrong. That person may very deliberately deviate from what you think is right for very good reasons!

BTW, I’m “just normal”, right handed myself.

(* I’m not suggesting PADI, CMAS or SSI state such a rule, actually they don’t. But many instructors do, and in my 2002 version of the SDI OW manual it’s mentioned on p. 39. This just to avoid blog blurring.)

- And, last but not least: We can’t be friends with everyone.

Again a tricky thing to say when confronted with such heavy criticism as mentioned in many posts on these threads. But we all befriend, ignore and defriend people on a daily basis, either with the click of a mouse, or through more direct social interaction. Well, when running a dive centre in a fairly remote location with very deep sites and dominated by currents that can be extremely strong AND unpredictable like we have in Pulau Weh, then of course it’s sometimes quite difficult how to phrase things telling a diver that he or she is maybe not be up for a certain dive yet, like joining to our site shark plateau for example. Or joining on a decompression dive to our deep wreck, the Sophie Rickmers. There’s surely some people who really don’t like no for an answer.

And then of course there’s very now and again the odd customer, who may get kicked out of a restaurant because he or she is misbehaving so much, that all the people at other tables start calling the waiter to pay and leave…..

Ok, so now that you also know what bias I have when writing all the following, let’s finally look at the

FACTS, FEELINGS…. AND FICTION

When still pursuing a corporate career before turning my hobby to a business (originally I’m an aerospace engineer), I learned a short phrase that was useful for dealing with conflicts with two or more parties involved. If you want to find a way out of the conflict in a manner that’s sufficiently acceptable to all parties, it’s not enough to just look at the facts, but we also have to look at the feelings of all involved. But what these last few weeks have shown me as well, is that now when the internet gets involved, it proves to be a strong catalyst for something that didn’t play such a big role in my work 20 years ago: There’s not only facts and feelings, but when the feelings (read emotions or convictions) are strong enough, people are also willing to introduce quite some fiction next to facts, mainly to try and give their post much more importance and attention than it deserves...

Now probably we all exaggerate occasionally or enhance things a bit, but with some of the post I have seen - and others noticed as well – the issues mentioned are really quite extreme. Then please consider the fact that Lumba Lumba already operates since 1998, and over the years mainly received good reviews. And still gets mails with compliments, also from people that were here the last few weeks after the accident. Also consider that all of these extreme postings are just from the last 6 weeks or so. As owners, my wife and me are still the same people. And staff, policies, and equipment don't change overnight. Well, there is a good saying about deals we regularly get offered by spam or pop-ups or whatever: If the deal seems too good to be true, then most probably IT IS (too good to be true). Well, please judge for yourself, but I have definitely spotted some post where I know that the opposite also holds: If a story sounds too bad to be true, then probably it is too bad to be true! I could point out quite a few remarks in different posts that are really fiction, but this report is already long enough as it is. So I’m not going to pay attention to all that, as I think you can all spot the fiction, the Baron von Munchhausen stories, easily yourself.

Now again, don’t get me wrong here, I’m not trying to discredit the main issue of the report as untrue, not at all, THE ACCIDENT DID HAPPEN!
OK, so finally what it’s all about:
(continue to part 2)

 

[LumbaLumba]

SMOKING

EMAIL CONTACT WITH GROUP BEFORE ARRIVAL

Fact: there has never been a question about our (non-) smoking policies before arrival.
My feeling now: knowing one of the group is fanatically anti-smoking, and one was trying to quit, it might have been good to ask us before, giving all kinds of options AND TIME to mutually deal with it beforehand. People visiting Indonesia frequently, know that smoking is common, probably even the majority of adult men still smoke.
Action: too late to correct.

SMOKING IN COMPRESSOR ROOM?

FACT: We have always had a strong no smoking policy in the compressor room! That a crew member with a package of cigarettes in his hand was seen leaving that room was already discussed with the person complaining about it on that group’s very first diving day. This discussion actually took place immediately, as Marjan passed right at the moment when the complainer told that crew member that he should not smoke near to the compressor. Behind the compressor room is what we call our “hot room” for drying wet towels, clothes and even customer gear on their leaving day, or comfortably changing clothes after a cool night dive, by making use of the warm cooling air from the compressors. That hot air is vented off by a high capacity fan to the downwind backside of the building. This air can not return to the compressors, as they take in their cooling air and intake air from the tank entry side of the building, getting a fresh sea breeze (more below). So the hot room is where some of the crew keeps their clothes, and of course regularly packages of cigarettes in their trousers. Thus the crew member seen leaving from the hot room with cigarettes hadn’t been smoking there at all.

My feeling: Though already discussed with the complainer instantly, it’s a pity this same story still comes back again, and is therefore meant to make the total report of Albion as big as presented.

ACTION LL: though all our crew knows and sticks to the rule that there can be no smoking in the compressor room (and hot room, though cooling air can’t flow back to compressors), we will put non-smoking stickers on, so also all our guests can clearly see that we have such a policy.

By the way, FACT: we have an unusual “open kitchen” policy regarding our tank filling, which is quite uncommon in the dive industry. Our divers can easily see themselves how we “dish up” our air. Also we are probably one of the very few operators in Indonesia and possibly even SEA to use the Bauer Securus filter monitoring system with the original, expensive Bauer filters without ever refilling them ourselves… (We’re a good customer of the Bauer agent Divemasters in Jakarta, so this is verifiable…) The Securus electronic monitoring units are clearly visible for anyone who cares to take a look.

REMARK: whole equipment area smelt heavily of smoke
FACTS: the area to gear up equipment is 4 m wide and 6 m deep. One of the 4 m sides is totally open to the very high aisle of our dive centre building. The opposite side of 4 m opens outside with 2 big sliding doors, offering a total opening of 2 m wide by m high. While gearing up doors are always fully open. It was an extremely busy weekend, so it can certainly be that 3 or 4 crewmembers were gearing up at the same time. Though they can’t smoke all the time while needing 2 hands for handling the tank/BCD/reg, I’m sure they do in between when putting checks on the roster, so I must admit that smoke will have been present. It was also indicated at the time by the complainer to our crew in strong terms.
My feeling: though cigarette smoke will have been present, I doubt that with all the open sides and even just the slightest breeze most people would have used Albion’s wording to describe the density of smoke. In fact, no one before April 2011 ever complained about this to us, or on the web (as far as we know). So to my opinion this is highly biased from the reporter’s side.

Note: what we do agree on though, is that the space is getting too small when it is as busy as during that particular Eastern weekend. But this has nothing to do with smoking, so more about that further below.

SUBJECT: compressor situation and chance of tobacco smoke to be drawn into the tanks from outside sitting area.

For tackling this item, I can give a short and a long technical version. At this stage, let’s settle for a (fairly) short explanation of our set-up first:

Most dive centres have a compressor that have a hose hanging somewhere, through which the compresser takes in its air for the tanks. If there would be little wind, and someone would smoke fairly close to the opening of that hose, the full concentration of the smoke going from cigarette to opening (assuming it travels that way) can get sucked into the hose. The cooling air for the compressor is (usually) a totally separate flow. With our compressors, that is totally different, as the air intake for the tanks is positioned where also the cooling air is sucked in. The cooling air is hundreds times more than the intake air for the tanks. So even if someone would lie smoking on the floor right in front of the main intake (the intake is low, floor air is cooler, and smoke and fumes tend to go up, so all arguments for Bauer to have designed the intake on these “silent” compressors close to the ground), the smoke would be highly diluted. Thus only a tiny fraction could end up in the tanks. This is very different than in most dive centres here in SEA! Still to get an idea, you could compare it with someone smoking next to that hose of the more common compressor with a very strong wind blowing. Then also the possibility of high concentrations getting in is much smaller, as most smoke will blow away with the wind…

The first compressor we used when we opened Lumba Lumba in ’98 was already this most expensive model Bauer compressor, when we still only rented a small former restaurant. So already at that time we pursued setting high standards.

FACTS:
For getting an idea of a full technical version, all our 4 compressors are Bauer compressors with the 4-stage K14 block as their beating heart (we have 2 more spares in the building in the back). The silent model with this block is the Verticus, which in it’s V10 version takes in 320 litres/minute for filling the tanks. The compressor has its own cooling fan on the block, but through the use of our hot room concept and an extra powerful fan, we force a bigger cooling flow of possibly as much as 5000 m3/hour through the 2 “open kitchen” compressors in the main building. Thus the dilution of any smoke that might coincidentally enter the compressor room stands at roughly a factor 250! Or staying somewhat at the conservative side because of resistance, say still a factor 200! (Ref: http://www.construlink.com/LogosCatalogos/sp_axial_compact_plate.pdf model fan hcfb/4-400/h)

That week we were only running 1 compressor (nr2). We would have run 2 because it was busy, but on that same Saturday, an electronic component in compressor 1 failed, and we had to wait for a spare.

From compressor intakes to door is 2m. The door is 1.20 m wide and 2 m high. From intake to the closest bench of the sitting area under the tree that saved both Marjan and my life at the time of the tsunami (FACT) is 8 m. The bench further away is at 10m from the compressor intakes. Any sea breeze present, will cut through this shortest distance perpendicularly. Occasionally it can be windstil, but it hardly ever is.
My feeling: NO WAY can significant amounts of cigarette smoke from this sitting area get into our tanks. And even if it would. It would be extremely diluted. So to my opinion the words “certainly.. tabacco smoke..drawn into the tanks” give a highly biased representation of the facts.
Action: At this moment, none by us. But anyone with a tester is welcome, indeed, I don’t have one (yet).

FYI

We can upload some pictures and drawings showing the layout of the shop, with the gear-up area, the equipment area and plastic customer gear boxes, the equipment rinsing area, the “hot room”, the compressor room and its distance to the outside bench/sitting area for the crew. Also we have pictures of the boat after the fire which shows that it was hardly affected. Only fuel itself, plastic and hoses burnt. But none of the wood. Same with the engine, it only needed minor repairs to run again.

REMARK: We mentioned this to dive crew who were rather blasé.
(and more smoking remarks)

Yes, I’m really sorry, but here comes the less civilized part where the yes you did/no I didn’t shouting starts. I don’t like it, and thought long and hard about it, but there ARE at least two sides to this story, and when someone is going on a public rampage to destroy the longstanding good reputation of a dive centre just because of one bad apple and a very unfortunate accident, then certainly I also have the right to say something to clarify why I came to a certain decision at the end of that very hectic day. He’s still anonymous, me, my wife Marjan and Lumba Lumba are not, so who’s got most to lose?

I can’t call it fact, as I wasn’t present at any of the confrontations with the crew, but most of them and some customers too used totally different words when describing how the complainer “mentioned this”. And by the way, it wasn’t “we mentioned”, plural, but just him, singular! Their versions included him commanding them to smoke elsewhere, slamming an ashtray on a table and other rude versions of “mentioning”. So our crew may have looked rather blasé to him, but when they reported later to Marjan and me, words like shocked or appalled are probably more appropriate. When Marjan had an earlier talk with him discussing his complaints it suggested a mutual understanding. But similar behaviour later on led to three customers cancelling their afternoon dive with him on the same boat. 1 person changed to another boat, 2 changed to a beach dive.

My feeling: this customer “in my restaurant” started to annoy the people on other tables, and I couldn’t let that escalate….

FACT: So as our plans were set to leave for the Netherlands the next day, I decided to address him about the confrontations I had heard about. That evening was the last possibility for a direct personal conversation. I took 2 beers from the fridge, offered him one, and asked if we could talk. He accepted, and we sat down on a bench in front of our dive centre, but sufficiently away from other people.

My Feelings: To get to know him a bit first, to try and find common ground, of course I asked him some more about his background. I think that’s just normal to get to know each other, but if he quickly felt I was looking for an opportunity to discredit him, it merely indicates that we were never going to be friends right from that very start. Yes, I had had a stressful last day before leaving, so surely wasn’t at my best. And maybe he didn’t have his top day either, and yes, it was probably also our male ego’s clashing at 6.8 on the scale of Richter. So the conversation wasn’t really helping much to reach mutual understanding. Actually what I recall was that it ended more like an old broken record, repeating the same groove numerous times “…so you don’t care about safety!” “Yes, I care, but I can’t change policies and long standing habits now immediately overnight, just for you”, “so you don’t care” “Yes, but..” etc, etc. People who remember the Monthy Python’s “This is not an argument” “Yes it is!” scene can surely imagine our scene as well.

In short, we were getting nowhere, and “managing my restaurant”, I did ask him to adjust or decide to dive with one of the other dive operators on the island (singular, I only addressed him personally!).
We parted with him saying he understood. He joined our boat dives the following days, and I must be honest that according to my crew there were no more confrontations till the accident happened some days later.

But telling from the tone of reporting by Albion, I can only conclude that at the end of that first day, it was clear that Lumba Lumba and him had started off on the wrong foot, and it’s logical that this already must have had some impact on the rest of the group as well. (Again, my feelings of course.)

And that after the accident feelings changed drastically, is fully understandable, given all of the above…..

 

[LumbaLumba]

THE ACCIDENT

THE FACTS

On the first extensive meeting we could coordinate ourselves last Friday 3 May with all crew that was present on the boat, we made an extensive analysis of the course of events, with a timeline of who was where and doing what at what time, and what happened with the boat and engines along that same time line.

What we found as a sequence roughly follows the same lines as described in the first hand account by a female member of the group who did not join to a more difficult site, and alternatively joined the unfortunate boat that had the fire. Of course we got more details (more people know more, simple as that), so here are the items that I consider most important:
- For trips that are further away, close to or around the KM zero, northern tip of the island, we always use three 40 HP engines on our wooden boats, so in case one fails we still have two left for sufficient speed and an extra spare on the side of the island where less other boats go.
- Every morning before going out with guests, the boat crew prepares the boats and checks all engines by running them for a while, also allowing them to reach a good operating temperature. At time of check that day, all were OK.
- The boat went out with 15 people; 9 diving guests, 4 dive crew, 1 captain and a second driver/boat helper (asked orally in meeting, and then verified with triplist and customer bills).
- When going out, both side engines started properly 1 by 1 (we go out along a line on a single engine and after that start up the others, middle last.
- When trying to get the middle engine going, it didn’t want to start.
- Because trying to start a 40 HP engine is quite tiring to give it the proper yank with the cord when doing it a number of times in a row, all Indonesian crew on the boat (captain, 2nd driver and 2 dive guides) took turns. So they were all in the back.
- Not starting up can of course be caused by a dirty, or detoriated spark plug, which can easily be cleaned or changed at sea, even while the boat is going. This is a pretty standard thing to do.
- Our captain checked the plug and changed it with a new one.
- He did not close the lid when trying again (don’t judge immediately here, please bear with me, we will get to the feelings later)
- Upon trying again with the new spark plug, he pumped some fuel with the handpump that’s in the feed hose to the outboards, and he adjusted the gas throttle a bit higher.
- He tried to start but still couldn’t manage, and another crew member took over, who succeeded to get it going. The captain took control of the machine again, but it wasn’t running well yet. When trying to rev the engine a bit, searching for more power, suddenly the engine caught fire. (When checking the engine later, the mechanic we usually ask to repair and maintain our engines found a faulty wire to one of the sparkplugs. See also down below.)
- In a reflex the crew member that had taken over the “kemudi” engine, winced backwards while shouting. (If immediately you are letting your emotions soar here, just think if you are a 100% sure what you would have done with such an unexpected thing happening right next to you?) The kemudi is the engine used as rudder, and is the right engine when looking to the front of the boat (starboard). The other engine(s) follow passively.
- With the captain focussing on the fire, unfortunately now no one was left at the rudder engine, which kept running….
- Then other crewmembers (closest to what was happening) jumped in panic reflex as well with one of them being adamant he really loudly shouted “jump”. But just like the shout of the first crew member that rolled back overboard, the shout may not have been loud enough for all to hear.
- The captain tried to put the fire out first by wetting a towel and covering the engine. He also added an extra t-shirt he had wetted, but he quickly realized this did not work. Thus he switched to grabbing the hood/cover of the outboard to use instead of a bucket to catch water. All local boats have buckets on board for taking out bilge water, but in this case the hood was the fastest thing he could find for that purpose. After he managed to soak the deck part just in front of the engines as much as possible with seawater and thought most of the burning plastic and hoses were already out, and suddenly noticed that everyone else had already vacated the boat, he quickly switched to moving the jerry cans to the front, out of their designated compartment.
- After this, the main difference in detail with this part of Albion’s report is that when the boat turned in a circle as described, I must be honest that actually both outer engines were still going, but by the time the boat got towards our diver from Belgium, the middle motor had already stopped because its fuel hoses had burnt, so the engine itself was cut off from fuel.
- At the time she was hit by this side of the boat first, the captain could not see her immediately, he was too busy with getting the jerrycans away from the danger zone.
- After being hit quite hard on her thigh by the boat, resulting in some scratches and a big bruise, her wetsuit got caught in the propeller of the “kemudi” engine, and she cut her foot somehow. Assumption: we think it’s most probable that her foot hit the vertical fin at the bottom of the engine, also fairly sharp, but not the propeller itself. If so, the injury would probably have been much worse.
- By the time the captain had finished moving the 3 jerrycans that were present, he ran back to the engines to see if he could get the 2 outer ones which were still running on their residual fuel out of gear into neutral (so prop would not be spinning anymore). The time he reached the aft, the position of the boat and wind was such that flames were mostly going to portside, so he ducked to the starboard kemudi engine to put this one in neutral, and then it was for the first time he noticed the difficult situation that our Belgium diver was in.
- He managed to reach the gear handle and got it in neutral, and while doing so sustained a cut and a burn. How exactly, he can’t remember and is not so important either.
- Almost instantly the Belgium woman could struggle free from the engine herself.
- One of our crew members shouted to all to swim closer together, and also the Belgium woman could manage to swim and get close to the others for pick-up by another boat coming to help. He checked that all 13 divers were present and noticed the 2nd driver was swimming towards the boat.
- From the moment the engine caught fire,the boat came to a halt after more than 2 full 360 degree turns.
- The 2nd driver climbed back on the boat to help the captain. There was only little fire left, he took over from our injured captain to put out the last flames using the same engine cover. (the helmet described is actually kept on our small fiber boat, which was used for the replacement trip after that).
- The captain had stayed on the boat till the very end.

After

- One of our crew members suggested a meeting for post traumatic counselling, and a meeting took place with all diving guests who had been on board.
- Of all 9 diving guests on board of the accident trip, only the Belgium woman did not join on a replacement morning dive, and the afternoon of course she couldn’t either. She was injured. All other 8 divers did, 6 going with our small fiber boat, and 2 AOW students switched to a navigation dive from the beach (that fiber boat is too small to take all 8 plus dive crew).
- Still four of these divers joined on the afternoon trip on another wooden boat, including the woman of the 7 pax dive group who wrote the accident part of Albion’s report (again, don’t judge too fast here, making choices evaluating risks is not easy, see below). 4 divers could not join in the afternoon because of no fly limitations.
- In the evening or on the morning of the next day, the 7 pax group told our crew not to join boat dives anymore, and switch to beach dives only.
- The day after, Friday 29/04, 11 other guests continued doing boat dive.
- Billing for the group was adjusted accordingly (beach dives are cheaper than boat dives).
- And indeed we made a mistake with the bill of the woman reporting, but it was NOT because we were so heartless to charge her for the trip with the accident, but because we overlooked she had not joined on one of the 3 boat dives that were actually done by the group the previous day. (No need for further details, we are in direct contact with her about this).

FEELINGS

Yes, sure, as I said right at the start: very shocked! So respecting others feelings on such a dramatic even, I can understand that phrases like “screaming for life” and “chopped up” were used, especially when someone was at a position most close to her! But for most readers it means that they imagine injuries much bigger than what the Belgium woman (Dorien) actually sustained. Her own story you can find elsewhere on this same thread.

Then let’s split things up in separate issues we can discern, and have a look at that.
But when doing so, I know that the difference in standards as expected in the West, and what’s realized here in remote locations, can be big. And each and everyone judges the importance of these differences in their own way, paired with their own feelings. So let’s not go into that quicksand area!

So just a couple of remarks as a reference/questions for a self-check:
- Though rationally, scientifically and technologically highly advanced, Japan still allowed smoking on domestic flight till in the late 90’s. (Didn’t google it, but asked a Japanese friend)
- Do you have a fire extinguisher in your own home? In your car?
- If I have a classic car in its original state, will you join for a ride knowing it has no airbags? And suppose this classic car is exempted by law for seatbelts, will you join knowing there are none? And what if I tell you the brakes are quite dodgy? So at what stage you say no?
- Do you want to know if the Jeepney you board in Manilla carries a fire extinguisher?
- Have you ever dived in a remote place, asked about the nearest deco-chamber, and then not use a helmet on a rented motorbike at the last “no fly” day of your dive trip?

OK, you catch my drift, we all make choices, and one poster already compared diving in Pulau Weh with climbing the mount Everest, with similar intentions as me. So it’s knowing your own choices and accepting the responsibility for it. Now of course this doesn’t mean that stating this allows us negligence! On the contrary, we DO strife for improving standards all the time. So let’s cut all those negative feelings about us lagging too far behind out of this part of the discussion, and focus on the positive actions we can take to improve and catch up. While remembering that Rome wasn’t built in a day, and Lumba Lumba needed to be built twice:

ACTIONS

Issue: Changing spark plug at sea while cruising

Please understand that our guys are good drivers because they have the manoeuvring experience from when they started learning at a young age. But that was often on their own, and certainly with one engine only. So any engine failure HAD to be tried to be repaired at sea. Being used to this, they just wanted all customers to have the usual speedy trip, knowing the 3-2 engine difference is about 15 mins.
- Action: Now, new policy: still ok to change spark plug, but close hood before trying to start again. Trying further steps at sea to get an engine going again will not be allowed anymore when still two engines available. Brief divers on reason for getting there at a slower pace. Relax and enjoy the ride.

Fire extinguishers

Yes indeed, there were no fire extinguishers on the boat yet. Just a bucket or the hood of an engine. Well, 5 years ago we did not even have one in our shop yet, than we had, and later also for our generator too., For our new engine storage it was already planned to get one, but still on the building Rome list. Action: Will be done soon, is easy. Now for our boats it gets more complicated, because the usual models corrode quickly, so on our boats they might maybe not even last a year. They have to be marine grade. Now that’s a bit of a mission impossible in Banda Aceh… But we’re open to advise, and just as some people are pushing their CO testers on Scuba board, maybe someone can help us with some advice for proper extinguishers to put on our boats? Maybe Albion himself has a positive suggestion? Action: as soon as we know a good choice available here in Indonesia, we’ll purchase and install them!

 

[LumbaLumba]

Open jerry cans with gasoline

Before getting to the factual situation on the wooden boat at the time of the accident, I must make clear that when not too busy, its always our big fiber that we are using first. That fiber is a customized Explorer 320 boat from Malacca Malaysia, and complies with Malaysian government regulations. It has one big fuel tank in its own sealed central hold. This also means a double firewall. Parts of the feeding system to the engines consists of long metal pipes, so a fire can not backlash to the tank due to lack of oxygen. Thus on this newest boat I assume that fire risks are considerably less.
Action: slowly, slowly we want to replace our wooden boats with fiber ones and we were already in contact with the same factory for ordering our second 320.

Please let me clarify here some more about how all local wooden boats meant for outboards are made. Going from the back to the front of the boat, you first meet the engine, then the “bench”, the transom, on which the engines are mounted on. Then in front of the transom there is a slanted wooden deck to prevent waves coming in from the back when the boat is stationary. This deck stretches forward for just over 1m to give the engine and gas handle of the manual outboard (no hydraulics) enough space to swing freely. In front of that we have the compartment holding the jerrycans with fuel. This compartment has a lid that hinges on the front rim, and the hinge is a piece of tough fabric (old weightbelts actually), through which nothing can enter into the compartment. During normal cruising this lid is always closed, so ash from a cigarette or a cigarette butt can not enter this compartment when cruising (air stream from cruising going from bow to stern).

I must admit that in this case the crew had opened the lid to get to tools, a new spark plug (always spares on board), old towels and such for working on the middle engine. A locking piece of wood is there for keeping the lid open, and indeed that was used in this case. So the writer of the accident part could easily see the jerrycans. The jerrycans have an opening of 4.8 cm in diameter for filling them or for putting the engine hoses in (kerosene engines have 2 hoses by the way, of which one can be used to feed the much cheaper, but more difficult to ignite kerosene (minyak tanah in Indonesian). But we ran them with a 100% petrol/bensin on that day, meaning both hoses per engine were fed into 1 jerrycan per engine.

Usually we close the opening of the jerrycan with a screw top that has 2 holes in it, in which the feed hoses to the engines fit tightly. So normally when cruising, it’s these seals on the jerrycans that already form a barrier against fire, and then also the lid of the jerrycan compartment is closed as main barrier, meaning 2 barriers in place. Daily operations of many of these boats in the Aceh province have proved that these barriers work sufficiently. Also in this case, thanks to our captain’s effective actions, the fire never even reached the jerrycan compartment.

However, we do admit that risks on that day were considerably higher than should be, as the lid was open (already discussed), but also the screw tops with holes were not in place on all of them. So its correct if the female reporter mentioned that 1 or 2 of the jerrycans were open without the screwtop in place (our crew is not sure anymore). But the opening is considerably smaller than mentioned.

Now I can look for excuses as to why this was the case, main thing being that no one sells the screw tops separately, but that’s not the point of course.

Fact is that some of the screw tops were not in place, and we have corrected that already. Only thing we’re still figuring out now is how to secure the tops with some kind of lanyard to the front rim of the jerrycan compartment, making sure not to lose them. Small action, but highly effective.

And of course the lid must be closed immediately again after getting tools and a new sparkplug. Repairs beyond that were already discussed above.

Kill switch

Currently we’re actually the only dive operator so far with a fiber boat with hydraulic steering console that includes a proper kill switch system.

The way our old type of wooden boat/(kerosene) outboard engines are operated, do not go well with kill switches, especially not when operating with multiple machines and a single driver/2nd driver busy helping divers/gear. There are a number of very valid reasons to explain why “the seatbelt” in this case is actually more of a hazard. We don’t have moorings for example because of the strong currents, thus need to remain flexible in manoeuvring switching back and forth to 1 or more engines, both while divers are down, and when they need to be picked up after surfacing. From origin not a single boat driver on the island is used to kill switches.

Now for our 2 – 3 engine wooden boat set-up, we will look into things more closely to try and figure out a suitable alternative instead of the kill switch. Maybe something like emergency gear to neutral extension rods or whatever that may work? Suggestions by people who have experience with similar engine set-ups as ours are welcome.

Crew organisation on boat during emergency

Analysing the local crew/dive guest interaction at the time of the accident, we certainly see room for improvement as well, as all were focussing on the engine problem in the back. Nothing like a pilot/cabin attendant task separation, so there was no more link between them and all divers in front. Also you can imagine how our 2nd driver feels, when on instinct and in an instant he picked the less heroic of the fight or flight buttons…. Again, are you sure what you would have done? So this is difficult terrain to deal with, and I can not conclude on any specific actions on this matter yet, apart from saying “that we will look into it”. But to find proper formal training here, like for people working on offshore oil rigs for example, I expect that will be difficult…. And again, all recommendations welcome.

In water management

I think this was handled quite well. When having DMT’s or new Instructors in our team, I always make it a personal mission to hammer on to the fact that they should always know on any trip they join how many people are on the boat in total, and not just for the the group they’re guiding. I see no problems regarding that here.

Aftercare

One of our crew members was professional enough to think about this explicitly, and called for a meeting to lower the threshold to talk about things to reduce post-traumatic stress. Sure, he was not specifically trained to actually deal with this, like a professional post trauma consultant from the police would be for example. But how many people are for a situation like this? Most important: he aimed for it and did the best he could. In this case, I can only remark that maybe the focus was a bit too narrow, as also people non-present on that boat were emotionally affected by it. But that’s hindsight on a singular, exceptional situation. It’s a point of attention, but not something I can easily translate into: action…

Reporting

Even though Albion may have waited first for us to react, no member of the group ever reported their dissatisfaction directly to us. Though they knew we were in the Netherlands, of course we were still checking our email daily. That’s only logical when having your own business. It was through DAN that we had to hear it first, on a Friday. And immediately after that weekend, on Monday the postings on ScubaBoard and ScubaSG were already done. We think that’s a pity, putting it mildly.

Most likely cause of fire:

Lots of speculation possible here, but given the fact the mechanic found a faulty lead to the spark plug (I could not check anymore, because when I returned a week ago, hoses and plastic parts were alreay replaced to get the engine going again, it wasn’t damaged that badly), and given the fact that the start of the fire coincided with revving the engine, we think that the chances are quite small it may have been caused by something else than that faulty wire. All four local crew had been busy with both hands, surely not smoking around that time, and as already stated before, the captain himself is a non-smoker. We also went through the list of foreign divers aboard, and the instructor had refrained from smoking on the boats since the discussions on Saturday, the female diver of the group who did not join their groups trip to Meuduro did not smoke on the boat (trying to quit), and of all others on the list, we are only unsure about 2 of them.

Yes, and then finally the hottest issue of all: Risk evaluation in relation to smoking on board.

Well apparently the verdict for the expat group from Singapore finally got clear that evening after the accident: now we have the feeling it’s like stepping in a car with no brakes. But all other divers at Lumba Lumba who were with us at that time didn’t see it like this (as far as we know). For them I guess it was more similar to the no airbag or no seatbelt equivalent. Different people judge risks differently. Now don’t get me wrong again, I’m not using this as an excuse for not taking any actions to improve like those mentioned above, not at all, but it does make things quite difficult to say what action we’re going to take regarding our on board smoking policy (BTW, remember we’re non smokers ourselves since 10 years). From the above it’s clear we ARE going to take specific actions to increase fire safety, but for a full on-board smoking ban, I must be honest that our own verdict isn’t out yet.

At this stage I can only say that we’ll look into it. And we’ll casually enquire with people over the coming weeks, what they think themselves and what their experience was on other dive boats. Also we know the world is changing quite fast regarding this aspect, so we’ll see over the coming few months or so…

 

[LumbaLumba]

Miscellaneous

I know, it’s a long story. But Marjan and me made a decision from the start to either try and tackle things thoroughly, or don’t do anything at all.
So some final items that are of less significance than the accident and smoking issue:

Remarks: about our slogan dive with fish and not with divers, plus sand everywhere…
Fact: Just look at the ratio of dive crew (4) to dive guest (9) on the boat that had the accident as an example, and you know what we mean for underwater.
Feelings: yes above water it was a totally different situation in terms of busy-ness, when this group was here, as it was Easter. And for us that’s often the biggest peak of the year together with Chinese New Year, usually bigger than X-mas/NY. So above water on our boats and in our shop, I don’t think it could have come as some surprise that it would be quite hectic. Still, despite the negative perception of the group, our dive centre is getting more and more popular, and more often our room for gearing up gets too cramped.

Thus, actions planned for the next half year are:
- Putting up extra BCD racks on the wall above the place where the tanks are.
- Double the capacity for crates to store personal gear
- Put a special table up for setting up cameras, and
- Create outside gearing up benches, with each bench designated for one of our boats.

Remarks: about briefings, depths, buddy checks etc.
Fact: most of the group are experienced divers
Feelings: Our main mottos at the start of this long posting have a high impact on how we see what a proper “brief” is. In our opinion there are 2 types of briefings on the opposite sides of the spectrum: short version – full version. Compare the full version with the story of the cabin attendant doing the safety drill: she (he) has to do all, and each time, as it is mandatory in case someone never flew before, forgot about it, or whatever. When flying often, you still listen? On the other side of the spectrum is Bob Halstead’s ideal briefing for when he’s diving with experienced divers: a drawing with a wavey line for the surface, an arrow down, an arrow in an oval/circle below it, and an arrow up. Briefing to go with the drawing: we go down, look around, and come up again… Now of course I exaggerate here, but really, why would we ask for a mandatory buddy check for people with hundreds of dives? So this is all about knowing who you’re diving with, and what makes them kick. So our policy is to only give a full version before the very first dive of a diver newly arrived at Pulau Weh (but still adjusted for level of training and experience), and for further dives it’s mainly how deep, what does the site look like, what current can we expect and what’s there to see. And that’s it. And as quite a few posters have expressed: that’s the flexibility and personalized diving that people love diving with us! And similar remarks I can make regarding the underwater guiding part too. Like some experienced divers don’t mind at all focussing (literally) on an object for quite some time while the guide keeps an eye on things from almost the edge of vision. And others really love being shown things staying close to the guide regardless of their 1000 dives… Plenty of good reports here in the past, and also even more recently than this group, so really, I don’t know what went wrong here, but personally I mostly blame it on the bad start on that very first day.

Remark: about currents, they should have a basic understanding of the tides
Fact: I’ve done the majority of my first 400 dives in the Netherlands, still as a hobby. About a 100 of those dives were in the Oosterschelde and on Northsea wrecks, both exposed to tidal currents (the rest was in lakes).
Feelings: Of course I learned about tables: very useful, THERE. And on those locations, I wouldn’t dive without them. Also when we worked on the West coast of Thailand for half a year. But now come to Pulau Weh and live here for 16 years, and see that the current can change 2 times within the time of one dive…Due to the position of Pulau Weh and its deep, complex underwater topography, all kinds of 3D turbulence is introduced when the moon passes, including potentially strong up and down currents. So we’ve learned it’s mostly quite unpredictable except for a few locations. But rest assured, we’ve also learned to read the current at that specific moment and make the best of the dive riding it, hiding from it and sometimes fighting it. And that’s with enough guides to take you safely around in small groups.

CONCLUSION

All who got as far as this, thanks for bearing with me.

Now looking back on the whole ordeal of the accident and the bad publicity involved with it, there’s certainly quite a few lessons we can learn from it. So on the contrary of things suggested, we do care about safety, and are always striving for improvements. If our attitude was to preferably ignore problems, we certainly would have never come as far as this, in 13 years forming lumba lumba from scratch to what we have now, with Aceh blocked for 1,5 years plus a tsunami in between.

Now many of the positive actions mentioned above were actually already planned before the accident and the report. But as mentioned a few times, Rome wasn’t built in a day.
But some new points of attention have certainly come up now because of what happened. And we’ll also strive to work on those.

Still, it’s not our intention to become like a very luxurious dive resort with spa, top-chefs and signs saying slippery when wet. So thus for those of you who would still like to step in my classic car without airbags but with proper brakes, please enjoy the ride.

Thanks for reading me,

Ton

Also on behalf of Marjan and Din

_________________________________

LUMBA LUMBA DIVING & LIVING

Gapang Beach, Pulau Weh
PO box 65, Sabang, Aceh, Indonesia

Tel/SMS (dive centre): + 62 811 682787

Website: Enjoy your diving with Lumba Lumba Diving Centre on Pulau Weh (Weh Island), Aceh, Sumatra, Indonesia
E-mail: info@lumbalumba.com
Back-up: lumbalumba.com@gmail.com

http://earth.google.com/:
5°51'12.35" N, 95°16'11.30" E

__________________________________

 

[Angel_diver_biker]

The reading of this extra long answer from the supposed owner of the dive center is so chocking.

The length, the style, the bla bla bla that never end, is an insult of the victims and customers.

Obviously this guy is so selfish to have some empathy and in this 17 pages (word doc) or 9600 words text, the word "sorry" is present only once!!! It emphasis every thing IMHO

But he did not forget to precise place and location of the dive center!

Thank you! A place I would personally avoid and strongly advise to any one not to go ...

 

[Centrals]

I really do not see any valid reasons for the staffs NOT reporting such a serious accident.
No excuse whatsoever!!!

 

[Cruiser24]

Personally I find it hard to believe/accept that upon your return to the resort after your trip back to the Netherlands, that none of your crew reported this incident to you. Unless you are telling me that your boats catching fire is such a frequent occurrence that it is no big deal??!!

Also, how many boats are you running? Hundreds? Thousands? You mean after you came back, you did not notice that 1 of your boats was burnt?? If so, wouldn't that have prompted you to find out more?

Additionally I believe Dorien, the injured diver stayed on in your resort to recover. Upon your return, you did not notice an injured guest at your resort? How big is your resort? How many guests were you hosting at that point of time?

 

[ferris213]

You seem to view this incident as proof that half assed procedures are good enough, rather than something that could have ended in a boat burning to the waterline and a woman being killed by the boats prop. How close can the Belgian woman have been from suffering massive injuries. In a remote area such as yours would she have stood any sort of chance?

If your approach to fire safety on a wooden boat with open jerry cans of fuel is "we can't use fire extinguishers because they get rusty" I shudder to think what your first aid capabilities are. Instead of making a snide remark asking if "Albion himself has some suggestions" (regarding suitable extinguishers) perhaps you, as the shop owner, could do the work and find something suitable yourself.

I can't believe you don't see this as a serious near miss that warrants a thorough revision of current practices.

Also, I'm not sure I would describe your local staffs failure to inform you of this incident as a good example of their leadership qualities. You said you were checking e mails every day while you were away on holiday... If a boat fire/ woman being struck by the outboard motor didn't warrant mentioning, what were they telling you.

You seem to blame Albion (the original poster) for not contacting you directly. Yet your own staff don't mention it and you say it's a good thing because it shows they accept high levels of responsibility. Unbelievable.

You're right, we can't be friends with everyone, and I really believe everyone makes mistakes, but this incident seems to have been caused by a combination of bad luck and a series of fundamental errors /omissions in your procedures. Yet you seem unwilling to acknowledge the gravity of the situation, or the lessons that can be learned from it.

Lets hope fire extinguishers make it to the top of you "building Rome list" sooner, rather than later.

 

[ZenDiver.3D]

My people tell me when a diver hits an urchin and has a few spines embedded. I really cannot fathom how someone's staff would omit the real injury of a customer and the burning of a boat. All the rambling above, does not help at all.