Catalina Diver died today w/ Instructor

[bsee65]

If I may paraphrase what was listed in the discussion thus far:

1. What caused the victim to initially decide to ascend? Described as panic due to perceived (not actual) OOA

I believe the report was that the OOA signal wasn't given until in the vicinity of 25fsw. Was that what the diver experienced at 65fsw? I don't think we know from what was presented here.

2. How rapid was the initial ascent? Rapid enough to cause the instructor to have to try and arrest it. The description of "bolted" was actually used by someone in the water with them and who knew the diver

The term "bolted" was used here only in relation to what occurred in the vicinity of 25fsw, not with the initial ascent. You may have heard that elsewhere, but it wasn't "board knowledge".

3. How quickly and by what signal did the instructor realize something was wrong, or was the instructor paying special attention to this diver The instructor was directly communicating with the diver because of her LOA/OOA signal

Again, the OOA signal was reported as being given after approximately 40' of ascent. If there was any hand signal prior to the initial ascent, I don't believe it was reported here. Was it just luck that the instructor happened to be well-positioned to make contact with the ascending diver? Was she there because she had a concern, or was that just where she typically positioned herself at this point in the session? Obviously, a diver ascending during the descent would catch attention, but either the initial ascent wasn't immediate and aggressive, or the instructor responded super quickly to maintain contact.

6. What caused the victim to bolt for the surface when she escaped the instructor? Wouldn't the diver be the only one that could answer this?

Definitively, yes, but here is where the OOA reportedly came into play. Medical info after the fact could tell us that there was some underlying reason for the impression of OOA with plenty of gas in the tank and functional gear.

7. How did the victim ascend, swimming or buoyancy control, and did that change at the point of "bolting"? Was there a pause at whatever depth the situation changed, or was the OOA signal given on the fly? As stated in the thread - diver perceived OOA at 65ft, "discussion" with instructor (including instructor looking at her gauges), then a rapid ascent with an attempt to slow it by the instructor, although unknown if it was due to inflating BC or just swimming. Instructor and diver arrested ascent at between 25 and 15ft, then diver separated from instructor and another rapid ascent to the surface

Again, I don't believe it was ever stated that the diver perceived OOA at 65fsw. The only report we have regarding the instructor looking at the victim's gauges came from drbill, supposedly occurred in the vicinity of 25fsw, and was later recanted. I also don't recall any statement that the ascent was completely arrested at any point, but may have missed it.

8. In retrospect, were there any signs that might have tipped someone off to a problem earlier? Not according to her boyfriend, who I talked with within 2 hours of the incident

But her boyfriend isn't a dive professional. Maybe an observation of how she donned her gear or something she did on Saturday may have showed difficulty or flaws in her technique that an instructor would have recognized.

9. What happened with the rest of the class? I met up with some of them at our hotel a short time after the incident. Are you asking how they ended their dive? As far as I know they did not continue diving that day.

Well, the instructor followed the victim to the surface leaving the other students and some number of other dive professionals at some depth. I was just curious as to how the message that class is over for the day gets back down to them with a message to ascend. Not every student ascending at the start of a class has the same catastrophic result, so, for all they might have known, the instructor would be back down in a few minutes. It has nothing to do with the accident per se, but there may be some advice for handling a tough situation out there.

10. What was the victim's actual dive history and skill level? All we know if that she was taking her advanced open water classes. I heard but do not know for sure that she was recently certified in perhaps March or May of this year, and had done some diving since.

I will admit that some of this information may not be accurate, and came from my memory of conversations with the diver's boyfriend and other members of the dive group, and additions made by Dr. Bill. They were short conversations, as I didn't feel the need to get into a lot of detail at the time. These people were still shocked by the accident, and needed to handle their own situations.

Thanks for the info about diving history.

 

[Thalassamania]

Bill ... come on ... she may be great, she may be poor, I hope that time shows her to be at least adequate, I have my doubts but I'm willing to hold the door open a crack till we have more firm data, but her students' appraisal of her competence is hardly germane.

And let's not forget, one of the ways to be OOA with a full tank is to not have your valve properly opened ... that's classic and rarely makes it into the report because so many people have fussed with the gear and no one actually remembers who opened or closed the valve after the rescue.

 

[drbill]

Thal... I can tell you she is a great instructor. I have observed her here for years. Her peers feel the same way. Her students are anxious to get back in the water (and they aren't OW students but higher cert levels). I think that speaks volumes. I don't see why you have your doubts based on what you know.

As to some of the points raised by others. It is my recollection that the initial ascent from 60-65' was with the instructor who was trying to slow her down. At about 25' the student apparently gave the OOA signal and then bolted to the surface. The instructor followed, but at a safe rate.

 

[merxlin]

Thanks for the clarification Bill. For some reason my memory failed me when I recapped the ascent (actually two ascents) issue.

@bsee65 - You raise a good question in how should or how can an instructor get information back down to students if they are at depth if the instructor is on the surface?

As far as her boyfriend not being a dive professional- I still would trust his instincts about whether or not something was wrong. He would have known her better than anyone else there, and I am sure would have noticed any abnormal behavior. The purpose of this class was in preparation for dive trips they were planning together.

>>>>>>>>>>>And let's not forget, one of the ways to be OOA with a full tank is to not have your valve properly opened ... that's classic and rarely makes it into the report because so many people have fussed with the gear and no one actually remembers who opened or closed the valve after the rescue.

Very good point and one I am surprised we didn't explore before now. It would certainly make sense: at 60ft on a slightly open valve breathing would get tough. But at 25ft, it should have gotten better, not worse. I guess the question is if you can get to 65ft on a fully closed valve?

 

[Bubbletrubble]

I guess the question is if you can get to 65ft on a fully closed valve?

Of course, you can.

 

[Leejnd]

Very good point and one I am surprised we didn't explore before now. It would certainly make sense: at 60ft on a slightly open valve breathing would get tough. But at 25ft, it should have gotten better, not worse. I guess the question is if you can get to 65ft on a fully closed valve?

WARNING WARNING pure speculation ahead:

Y'know, the concept of a closed valve is an interesting one, and I too am surprised nobody mentioned it earlier. It could have been one of those situations where her valve was already opened before the dive, but someone (thinking they were opening it) actually went and closed it, then cranked it back a 1/4 turn, so it was barely opened. I've read of that situation numerous times here on SB - it's commonly mentioned in the "don't do the quarter-turn" or "DMs shouldn't touch my valve" debates.

It would get harder to breathe as she descended. And then, yes, it would have become easier at 25. BUT...if she'd held her breath during the ascent from 65 to 25, then suffered a lung expansion injury and felt it, that could have caused the subsequent bolt. It's certainly not out of the realm of possibilities that a new diver would forget to blow bubbles during a CESA.

(Again, this is all PURE speculation...just exploring possibilities...)

This could be yet another lesson coming out of this thread...one that has been discussed numerous times (the quarter-turn and DMs-touching-valves debates), but I don't recall in those discussions anyone considering how such an error could actually prove fatal. Well, here's one way.

 

[drbill]

Ha... like the lead-in to your post, LeeAnne!

Don't have any answers re: the valve issue since it was not something anyone directly involved in the incident (including the responding harbor patrolman who I know) has mentioned. While it is valid to raise the issue, my understanding is that the total dive time was on the order of 14 minutes so it is highly unlikely it was a partially closed valve.

 

[Ayisha]

...I've read of that situation numerous times here on SB - it's commonly mentioned in the "don't do the quarter-turn" or "DMs shouldn't touch my valve" debates.
This could be yet another lesson coming out of this thread...one that has been discussed numerous times (the quarter-turn and DMs-touching-valves debates), but I don't recall in those discussions anyone considering how such an error could actually prove fatal. Well, here's one way.

The partially open valve is not an issue in this accident, as Dr Bill mentioned.

However, the above post makes it appear that turning the valve a quarter back is what causes the confusion and potential tragedy, not the opposite. It is the fully open valve that causes confusion among people trying to "help". It has been considered an issue EXACTLY because of potentially fatal consequences, especially in a situation where a diver performs a negative entry. Turning the valve fully on also has the potential for the valve to "stick", even with newer type valves, as I believe Rick Murchison pointed out a few years ago.

I stopped turning my valve on fully after too much confusion being caused; having to defend my choice after telling DM's if was fine fully open; DM tampering that could have caused an issue if I was not in the habit of checking my valve myself before splashing; and reading the threads and weighing the pros and cons.

If you read those threads about whether to do the quarter-turn back or not, you will see that there is very good evidence to do the quarter turn back OR don't let anyone touch your valve(s) and best of all, check your valve (and all gear) yourself before you splash. When a "pro" checks a valve and it does not turn both ways, they often assume (without thinking) that it's closed and turn it completely the other way (which may be off) and then a quarter turn back, which may be partially on. As mentioned elsewhere, if you are not overweighted and do a positive entry, no big deal. If you are overweighted and do a negative drop and descend quickly, it could use some time to get control of the situation and it is more of an issue.

Unfortunately, most pros seem to adhere to the quarter turn back and unless it becomes standard practice to fully open valves, you run the risk at some point of someone helping you quickly without thinking. It is up to us to make sure we can reach our own valve and to check our valve ourselves before each splash.

 

[Bubbletrubble]

While it is valid to raise the issue, my understanding is that the total dive time was on the order of 14 minutes so it is highly unlikely it was a partially closed valve.

@drbill: Based on your report in Post #55 of this thread, the incident occurred while the instructor and student were descending on the south boundary buoy chain. It was reported earlier in the thread that the incident occurred during the initial descent. 14 minutes seems too long to be consistent with that. Was the class doing some skills or swimming along for a little while before descending to about 60 fsw? It sounds like the ascent occurred rather quickly (1-2 minutes tops).

As to the possibility of a partially closed valve...
I was under the impression that if a valve were barely open then it might deliver some air (possibly with resistance) at shallower depths and provide no flow at greater depths. This would seem to be consistent with a scenario of OOA at depth (perhaps with a delay in signaling OOA) and the finding of sufficient quantities of gas upon retrieval of the diver's gear.

 

[Thalassamania]

As to the possibility of a partially closed valve...
I was under the impression that if a valve were barely open then it might deliver some air (possibly with resistance) at shallower depths and provide no flow at greater depths. This would seem to be consistent with a scenario of OOA at depth (perhaps with a delay in signaling OOA) and the finding of sufficient quantities of gas upon retrieval of the diver's gear.

Correct. For those of you who have not experienced this, when you look at you pressure gauge it will deflect to almost zero with each breath.