Cave diver drowns - Jackson Blue Springs, Florida

[The Chairman]

I would love to see your root cause analysis of this incident.

Le sigh. I've given my synopsis of this accident at least three times already.

I have never seen a car dealer walk around thumping their chest about how safety conscious they are.

You've never met a car dealer then. They just love it when their car makes this list: IIHS-HLDI: Crash Testing & Highway Safety

Fine. You hate Edd. You see him as the root cause of every cave death as well as inflation. That helps us understand this accident how?

 

[Biotech Diver]

I would love to see your root cause analysis of this incident. If you don't know how to do one you essentially keep asking why. When you can no longer answer that question you have arrived at the root cause. As far as comparing it to a car dealer I have never seen a car dealer walk around thumping their chest about how safety conscious they are. They certainly don't post on Facebook just a few days prior to this how they refused selling a car to an individual because they weren't experienced enough to handle the horsepower. The industry is supposed to be self regulating yet when you have the same people involved in incidents with the same root cause it's anything but the common denominator that was the problem. Carry on blaming gold line T's. Whoever put the line in etc. Hell why not blame Biden or Trump. That would make as much sense as what you are claiming.

Here is a video to help you out.

The 5-whys are just one of several RCA tools. It's my favorite tool for human error deviations. Other tools I've used in my job are the Ishikawa Diagram (aka Fishbone) and the Is, Is Not. Fishbone is a good tool when you think it may be equipment related. Is, Is Not is good to use when you don't know where to start. Root Cause Analysis is a very systematic approach and it works best if you don't go into it with preconcieved causes and you try your best to put your biases aside. If you don't, you may stop too soon in your RCA and not find the true root cause, or you may miss the true root cause because you went down the wrong rabbit hole. You also usually have some or many contributing factors that you need to address when you come up with your CAPAs.

 

[tomfcrist]

Who’d have guessed LEAN/SixSigma would find it’s way into scubaboard A&I threads.

 

[PfcAJ]

Cave fills are a long-standing tradition in cave country. If you don't like the practice drag more tanks. In any event, the amount of gas taken determines how far you can bail out from, in the case of CC. While it is comforting to dive within that limit, diver safety is the paramount concern.

It’s not just about distance. It’s about time.

Time matters when you’re working through a problem like being stuck or lost.

There’s a hang up on gas=distance like that’s the end all be all when it comes to cave bailout planning. There’s more to it than a simple math problem.

 

[bamafan]

It’s not just about distance. It’s about time.

Time matters when you’re working through a problem like being stuck or lost.

There’s a hang up on gas=distance like that’s the end all be all when it comes to cave bailout planning. There’s more to it than a simple math problem.

Exactly. My most commonly used tank in Florida are lp 120's. I don't dive them for penetration distance. I dive them for the huge thirds. The final third really lasts a long time. Having been stuck numerous times and even having my line cut behind a nasty restriction in Bozell when I was around 120' deep I can tell you it was calming to look and see I had 3k in each tank plus knowing I had 3 stages with one being a safety within a thousand feet of where I was. Sadly the benefit I hear most with the Sidewinder is that you don't need to carry stages and you can dive smaller tanks. My cave instructor told me that you should plan for any two failures. If you have more than that you are toast. With limited gas you are basically relying on not having more than one failure.

 

[bamafan]

Le sigh. I've given my synopsis of this accident at least three times already.

You've never met a car dealer then. They just love it when their car makes this list: IIHS-HLDI: Crash Testing & Highway Safety

Fine. You hate Edd. You see him as the root cause of every cave death as well as inflation. That helps us understand this accident how?

I don't hate him. I disagree with many in the cave community that put profit over safety but yet claim they are all about safety. Is it safe to teach mod 1 on a rebreather in the overhead? Is it safe to fill an ow divers doubles when he is cave diving with your tank monkey. Is it safe to lobby to have ow diving allowed on the Millpond. Is it safe to rent pontoon boats to ow divers and tell them where the caves are? I am waiting on your root cause analysis. I haven't seen it yet.

 

[The Chairman]

There’s a hang up on gas=distance like that’s the end all be all when it comes to cave bailout planning. There’s more to it than a simple math problem.

Time x Speed = Distance.

I didn't invent that formula.​

Gas = time.

I didn't invent that one either.​

Slow is smooth and smooth is fast.

Again, while I believe it, I didn't coin it​

Diving, be it in Open Water or deep in a cave is all about knowing and honoring your limits. These limits are based not only on gas, depth, and time, but on training, skill, attitude, the environment, physical attributes. as well as others. To paraphrase a famous movie line, "A diver's got to know their limitations!" Just because I, or anyone for that matter, points out a single limitation, it doesn't mean we're ignoring all the others. A rebreather opens up all sorts of caves to me, if I bring enough bail-out. My bail-out is determined using the rule of fourths, where my rebreather is the first fourth. Some prefer to use the rule of thirds, and still others reduce that even further. There are no cave police down there, nor do I want there to be. Nanny interference is one reason I avoid Ginnie.

While I plan for shite to go south from time to time, it can go far, far further south that anything I could possibly, much less reasonably predict. That doesn't stop me from planning using those time-honored formulae.

 

[The Chairman]

am waiting on your root cause analysis. I haven't seen it yet.

Then you haven't looked, 《mod edit》 No one goes into business to NOT make a profit. That's a far, far cry from putting profit first. You have an axe to grind about Edd and nothing will stop you from bellyaching about how horrible he is. It's just more cave politics and it silts out the discussion. 《Mod edit》

 

[nakatomi]

The line was placed by one instructor and several people have suggested it needed to come out, but we all know that would start a fecal storm

With all due respect, I believe this to be incorrect information.
This "one instructor" has not put this line in.
But it is probably really convenient to say so.

Not that it matters at all who put it in.
We need to keep in mind that a lot of the smaller stuff in Florida was lined in pure sidemount with smaller tanks like LP50s or maybe LP80s decades ago. Quite obviously there may be issues when diving the same passages now with additional gear like sidemount rebreathers and bigger tanks, not to mention as cave diving beginners.

It's either you let people figure this out by themselves, incorporate it into training and make them aware by some other means, or remove all the lines that don't fit 100% of the cave diving population.

The comment was made that if we are a full cave diver and doing those kind of dives we should know where we are in the cave.

Yes, I've heard that comment before and "should" is not helpful.
A lot of "should have" or "should not have" is not preventing any of the scenarios in these accident threads from repeating themselves.

How about the horseshoe circuit/squirrel tunnel mishap in the same cave by an out of state cave instructor (which lead to the squirrel tunnel being called the lost student tunnel)?
That instructor should have known too that he was on the wrong line.
The ones who fell victim to this mishap were his students, who got lost during class and luckily survived.
Sure the guy made a mistake. He thought he and his students were on one line, when instead they were on a sidemount only line - in backmount.
The line is still in there by the way and the person who lined it hasn't been put before a firing squad.

Those suggested warning markers would be simple indicators to those unfamiliar with the cave as to what type of cave to expect on this line.
I don't see why a single colored cookie ought to hurt any experienced cave divers feelings or how it would prevent anyone from learning the cave properly.
Also there may be better ways to solve the issue, this was just one idea and surely there are more.

I initially disagreed thinking it’s easier to look at a road map with street names. But the more I have been in that particular cave the more I agree with the no road maps. If you are a cave diver you need to look at every aspect of your dive and decide if any passage or any navigational decision you are making is the correct decision.

That's all fair and I agree.
What we just need to keep in mind is that JB is a tourist cave where beginners learn how to cave dive. This is the reason there is gold line, why jumps are cut back and so on.
This is all to protect those unfamiliar with the cave, and those who make navigational mistakes.
I'm not sure every little side passage needs to be marked by name. The idea is kind of cool, but it takes away the process of discovering it by yourself.

Maybe a little warning here and there (where warranted) might make sense.
Or just pull the line in the passage this accident happened in - and all other sidemount only lines at the Mill Pond too. There are a few that come to mind

Funny how people get offended by the suggestion of putting a marker on a line and feel their cave diving intelligence is insulted, yet instead they suggest pulling the line entirely to fix the issue.

 

[nakatomi]

It's about the industry

It absolute is 100% just that, in more ways than just one.

Just look at how and why GUE was formed.
One reason being the lack of training quality at the time and the unwillingness to change by the traditional cave training agencies.

To clarify, I'm not GUE trained and looking at this from the outside, but let's just ask ourselves this, maybe @PfcAJ can chime in.

Would a proper GUE team of Cave 2 divers with less than 100 cave dives pull through with a dive like this?

Would a sidemount rebreather be the recommended tool of choice for a new GUE cave diver?

Would a sidemount rebreather be the recomnended tool to use in a passage less than 600' from the entrance?

If any of these are a hard ""no", we might want to question the de-facto "standards" that exist in the industry today.