Error Blue hole fatality

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tommacao

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Location
Hong Kong
# of dives
200 - 499
Screenshot 2024-06-13 193437.png


I came across a post on Chinese social media called 小红书 , but I couldn't find any corresponding reports in English-language news sources. According to the post, it appears that a Tech instructor was leading a group of students on a technical dive to the Dahab blue hole in Egypt. Tragically, during the dive, he mistakenly switched to a 50% oxygen mix at an unknown depth, which led to him experiencing oxygen toxicity and ultimately drowning. However, it is important to note that the details provided in the post were somewhat unclear.

 
They normally have an ambulance pre-positioned at the Blue Hole right next to the entrance that technical divers use to get in the water. There are not many other dive sites in the world that do that.

But as over 200 divers are reputed to have perished there in the last 20 years or so, CDWS has decided to take precautions in the last couple of years. There are many, many memorial plaques on the wall there. I had heard that sometime around the early 2010s that additional plaques were forbidden to be put up. But there are several ones dated since then.

Tragic that they were not able to save him.
 
One thing I learned from a longtime cave diver is that you can very easily wrap part of a shock cord (bungee) loop around the regulator mouthpiece, in a way that makes it COMPLETELY obvious when you are about to put a high O2 regulator into your mouth. It came in handy for them in zero visibility conditions.

Loosely enough that it can be quickly removed, obviously, when it actually is time to switch to that gas. Others might use tape or something. Worth thinking about, despite the "hassle"
 
I have two questions:
  1. What are the standards for verifying an instructor's gas switch in tech training?
  2. What bottle would he be switching to at depth and why?
Regarding #2 - if he had a bottom stage, wouldn't it be normal procedure to breathe that first and then switch to back gas when the stage is almost empty? It seems unlikely that he would mistake the stage for his back gas if the stage reg was stowed?
 
One thing I learned from a longtime cave diver is that you can very easily wrap part of a shock cord (bungee) loop around the regulator mouthpiece, in a way that makes it COMPLETELY obvious when you are about to put a high O2 regulator into your mouth. It came in handy for them in zero visibility conditions.

Loosely enough that it can be quickly removed, obviously, when it actually is time to switch to that gas. Others might use tape or something. Worth thinking about, despite the "hassle"

This goes back to the fundamental issue of doing proper gas switches and buddy checks, which I am assuming is the core reason why there was a fatality in this case.

Instead of color coding regulators, adding tape, or covering the mouthpiece with bungee, why not just teach proper gas switch protocols? Visually verify the MOD, trace the hose from the first stage to the second stage, confirm bottle is turned on, have a buddy verify the switch, etc. etc. etc.. All things that should be taught VERY early on during tech training (regardless of agency).
 
This goes back to the fundamental issue of doing proper gas switches and buddy checks, which I am assuming is the core reason why there was a fatality in this case.

Instead of color coding regulators, adding tape, or covering the mouthpiece with bungee, why not just teach proper gas switch protocols? Visually verify the MOD, trace the hose from the first stage to the second stage, confirm bottle is turned on, have a buddy verify the switch, etc. etc. etc.. All things that should be taught VERY early on during tech training (regardless of agency).
Agreed in principle, and of course you describe how it's taught. We shouldn't teach clutter, or unnecessary crutches, as a substitute for effective procedures. Certainly not in [mostly] open water. But that doesn't mean it isn't helpful.

Why even label the cylinders? Isn't that a crutch too? Don't you know where your deco gas is?

It is totally possible to have the basic skill (gas switch procedure) totally mastered 99% of the time, but then make a mistake once. This apparently happened.

If this was sidemount tech, seems like it would greatly elevate the risk of confusion between cylinders.
 
It is totally possible to have the basic skill (gas switch procedure) totally mastered 99% of the time, but then make a mistake once. This apparently happened.
Which is why the team verification of the gas switch is part of the procedure, to catch those mistakes. It's very unlikely that both divers will make the same mistake at the same time if they follow a proper gas switch procedure.
 
Which is why the team verification of the gas switch is part of the procedure, to catch those mistakes. It's very unlikely that both divers will make the same mistake at the same time if they follow a proper gas switch procedure.
But it can happen. The WKPP had this very mistake on a dive, and the WKPP is famous for its insistence on proper gas switching technique. A diver in a group left his stage bottle on the depot for 50% bottles and took his 50% bottle to 200 feet.

We don't have any details on what happened, so let's not go too far on assumptions. When I have read reports on fatalities (and near fatalities) over the years, it seems to me that in the majority of the cases, the switch itself was fine. The problem was that what was in the tank was not what the diver believed it to be. The real error happened on the shore before the dive.
 
I have two questions:
  1. What are the standards for verifying an instructor's gas switch in tech training?
I don't know what standards were in force on this dive, but normally the gas switch protocol would be the same for the instructor as any other member of the dive team. They would get another team member (assistant instructor or student) to watch them switch while verifying the stage MOD label versus depth gauge, and hose routing.
  1. What bottle would he be switching to at depth and why?
Regarding #2 - if he had a bottom stage, wouldn't it be normal procedure to breathe that first and then switch to back gas when the stage is almost empty? It seems unlikely that he would mistake the stage for his back gas if the stage reg was stowed?
Right, the bottom gas stage would be used first. Apparently the details of this incident are unclear but what has happened in some other incidents is the diver starts at the surface breathing travel gas and intends to switch to a bottom gas stage or back gas during the descent. But then they get distracted and fail to switch as planned so they stay on the travel gas past the MOD. I'm not claiming that's what happened here, just a possibility.
 
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