Coroners Report. What do you think!

Please register or login

Welcome to ScubaBoard, the world's largest scuba diving community. Registration is not required to read the forums, but we encourage you to join. Joining has its benefits and enables you to participate in the discussions.

Benefits of registering include

  • Ability to post and comment on topics and discussions.
  • A Free photo gallery to share your dive photos with the world.
  • You can make this box go away

Joining is quick and easy. Log in or Register now!

Julius SCHMIDT

Contributor
Messages
532
Reaction score
357
Location
Alexandra Headland
# of dives
1000 - 2499
One that seems to have been missed when it occurred

I'll call it First World Country with Other World Ideas!

Diver who vanished at shipwreck probably drowned: coroner

Police resume search for missing diver

full.png


full.png

full.png



https://www.coronerscourt.vic.gov.au/sites/default/files/2018-12/karenyokeminglee_512212.pdf


Could the coroner do with new experts and find out where we are with this when to dump weight thing
 

Attachments

  • upload_2020-12-10_16-10-23.png
    upload_2020-12-10_16-10-23.png
    36 KB · Views: 74
  • upload_2020-12-10_16-14-44.png
    upload_2020-12-10_16-14-44.png
    11.2 KB · Views: 75
  • upload_2020-12-10_16-15-30.png
    upload_2020-12-10_16-15-30.png
    33.7 KB · Views: 67
It was because of the frequency of divers drowning having reached the surface but unable to maintain positive buoyancy, due to retaining their weigh belt that BSAC introduced mandatory weight belt jettisoning for each diver qualification course. Ocean Diver, Sports Diver, Dive Leader, Advanced Diver, and 1st Class.
 
Could the coroner do with new experts and find out where we are with this when to dump weight thing
And where are we exactly? I'd hate to ditch weights at depth, but it's better than drowning on the bottom.

It was because of the frequency of divers drowning having reached the surface but unable to maintain positive buoyancy, due to retaining their weigh belt that BSAC introduced mandatory weight belt jettisoning for each diver qualification course.
Yet still, most dead divers who are recovered are found with weights still on. I'm a clumsy vacation diver who practices ditching weights on the first dive of every trip, and it's interesting how much I have to think about it at the time. If a panic hits, I'll be grateful for the practice,
 
I disagree that it is the basic protocol to jettison weights and return to the surface quickly once you get into trouble. That should be an option of last resort.

I would hate to have to spend time trying to find students' weights after they practiced jettisoning them in the quarry. Even if they tried dropping them right over the platform, they are likely to end up in the muck.

I think the reason most dead divers are recovered with weights still on them is because they aren't drowning cool, calm, and collected. They aren't reasonably thinking "I should drop my weights to get out of this, but then I would have to pay to replace them!" Since coroners like to short cut it and call any death underwater a scuba related drowning, we don't even know if they were dead before they could have realized something was wrong. A heart attack, a blackout, cardiac arrest, embolism, issues from an unknown PFO, could all happen before a diver or buddy, especially one who is not medically trained, knows what is happening.

And people can end up doing all kinds of weird things when they are narc'ed. You can argue they should have known better than to ever get themselves in that situation, but at the same time, you can't because they don't know what they don't know. Narcosis affects everyone differently and for some people, in as little as a foot difference of depth, you could go from completely rational and self aware to suicidal maniac, no longer in control of your own actions. There are deep diving students who, when presented with simple math problems on a slate at depth, will draw a picture of a dog to answer 2 + 1 = ? and then have no memory of you even showing them the slate when they get back to the surface.

I also really wish the training agencies would have chosen better names for things. OW should be Basic OW. AOW should be Slightly Less Basic OW or Intermediate Open Water. The media likes to latch on to things like "Oh, she was an advanced open water diver. She should have known better!" But really, no, she wasn't really that experienced, and may have been even less experienced in the conditions she was diving in.
 
disagree that it is the basic protocol to jettison weights and return to the surface quickly once you get into trouble. That should be an option of last resort.
To clarify, yes, of course, I agree. But as a last resort, being found on the surface with a lung injury is treatable. Found an hour later, a day, a week, on the bottom not.

I would hate to have to spend time trying to find students' weights after they practiced jettisoning them in the quarry. Even if they tried dropping them right over the platform, they are likely to end up in the muck.
In my OW checkout, I think we removed our belts but held onto them. On my first dive of a trip, I practice pulling my weight pockets, but never drop them.

That time I screwed up messing with my camera and felt a slow drag on my reg at 50 feet, glanced at my Spg, realized my OOA, and did a CESA, I kept one hand on a weight pocket, but never had to pull it.
 
Wow. Where to begin? (For those who might not know, I'm the Forensic Consultant to the LA County Coroner for scuba fatalities and do expert witness work in scuba litigation.) Personally, I think there's merit in what the Australian Coroner suggests in terms of re-qual. Since when is more training a bad thing??? Couple of quick thoughts on their report (from the link):

Gear was found on bottom, body wasn't found - Did she make it to the surface and ditch gear and it sank? Did she wriggle out of gear on the bottom? No way to know.
Tank out of VIP - So what? Doesn't necessarily mean anything. Was there air in trhe tank when found? Was the air good? Was the tank interior rusty? Those things are relevant.
Dive shop rules out tank issues - I agree. A tank on the bottom for a few days can slowly (or rapidly) be losing air and eventually might let water in.

The other thing to bear in mind when sometimes reading these Coroner or Police reports, especially when written by someone who may not be a diver, they may throw in all kinds of comments or observations ("The dive slate appeared worn, as if it had been used before" - actual note from a USCG diving accident report) that may in no way relate to what happened or provide any insight.

And now a couple of thoughts on comments here which caught my attention:

"Did these divers not have a BCD?" - Plenty of dead divers found on the bottom with weights on and BC not inflated. Also in an OOA situation, if the diver make it to the surface and even in a state of panic tries to auto-inflate the BC, it won't. This is why weight-ditching a much better way to immediately establish flotation. (It's also more effectively in a place like CA where we wear thick wetsuits and have 20+ pounds of weight as opposed to a warm-water dive where you have a thin or even no wetsuit and the weight you carry is minimal.)
"I'd hate to ditch weights at depth, but it's better than drowning on the bottom." - Correct, especially on the second half of the sentence. Here's the deal with ditching weights underwater (again with the caveat from the previous comment above): You WILL eventually float to the surface. And an unconscious diver on the surface is easier to spot and try to rescue than one underwater when we don't know where you are.
"If a panic hits, I'll be grateful for the practice" - Yes.
"I would hate to have to spend time trying to find students' weights after they practiced jettisoning them in the quarry." - Would you rather spend time trying to locate their lifeless body, bring it to the surface, perform CPR, explain to the grieving family what happened, and then spend a year or two defending wrongful death litigation? This isn't about YOUR inconvenience. This is about instilling in them a rote skill that might save their life.
"Since coroners like to short cut it and call any death underwater a scuba related drowning . . . " - Not true and a cheap shot. Also you should understand that in Coroner World, drowning is a finding of exclusion. In other words, person was found underwater (or had been in the water) and we've ruled out everything else so the only thing left is drowning. You basically can't really "prove" a drowning. Also, unless foul play is expected (which is usually isn't), there comes a point where you need to close a case and move on. In LA County, the Coroner Department does about 10,000 autopsies a year plus looks into other cases where autopsies are not performed. You don't want to rush through anything but you also don't always have the luxury of spend as much time ruminating as you'd like.
"And people can end up doing all kinds of weird things when they are narc'ed." - 47% (DAN study) of scuba deaths have out-of-air as a trigger. Narcosis generally is not a factor in fatalities.
"I also really wish the training agencies would have chosen better names for things. OW should be Basic OW." - I agree. Some titles (Master Diver) may give people a false sense of knowing more than they do.
 
I will repeat here something I have written many times in the past when dealing with threads about divers being found with their weights on, with people assuming they did not think to drop those weights. Many years ago, in response to one of these threads, I went through a couple years of DAN injury reports and only found a very few instances in which failing to make a decision to drop weights MIGHT have been a factor in the diver's death. Here is a quick summary.
  • The largest category for fatalities by far is medical issues, including especially cardiac issues. In most of these cases, the divers are suddenly incapacitated. People suffering from sudden cardiac death are unable to drop their weights, and if they somehow did, it wouldn't matter.
  • A joint PADI/DAN study 7-8 years ago found that the the most common cause of death in a preventable, training-related accident was an embolism following a rapid ascent to the surface, during which it is likely the diver held his or her breath. Divers reached the surface and then died there. Dropping weights would not have helped; in fact, it might have made it worse.
  • As was true in this case, in many case divers are seen ascending with no problems and then never seen again. (I know one such case personally.) Since the diver was ascending with no difficulty, there should be no reason to drop weights, and in most cases it is likely the diver was incapacitated by a medical event and would not have been able to drop weights.
  • Dropping weights while entangled or lost in a cave or wreck provides no benefit.
  • A surprisingly large percentage of divers are found after being separated from the buddy, either intentionally or unintentionally, with no clear sign of a reason for the death. Sometimes the diver's cylinder is empty, with the regulator out of the mouth. In such a case it is possible that dropping weights could have helped, but it is also possible the diver died for other reasons and had a free flow that drained the cylinder. In one case I know well that was intensely studied, the diver was with a group that had surfaced very near shore at the end of the dive and headed to shore. The diver in question indicated having plenty of gas in the cylinder, far more than necessary for the short swim to shore, and the diver decided to swim in underwater. A search later found the diver with an empty cylinder at the point where the diver began to swim in to shore, and an autopsy showed no cause of death other than drowning. Such deaths are a mystery, and you cannot simply assume dropping weights would have been a lifesaver.
It is helpful to imagine the circumstances under which it would be necessary for you to make a conscious decision to drop weights at depth. There are such scenarios, but they are by no means common.
 
"And people can end up doing all kinds of weird things when they are narc'ed." - 47% (DAN study) of scuba deaths have out-of-air as a trigger. Narcosis generally is not a factor in fatalities.
Could you please cite that study? Every DAN study I have looked at lists medical events as the largest category of scuba fatalities.
 
Could you please cite that study? Every DAN study I have looked at lists medical events as the largest category of scuba fatalities.
I think it's in here (attached). This is the summary of the proceedings from the DAN Fatality Workshop in 2010. It was a study by Dick Vann (and someone else).

An informal non-peer-reviewed study I did a few years ago of DAN fatality reports from 2003-2006 (327 cases) came up with the following as cause of death after reviewing the facts of the case as presented by DAN:
• 69% - Diver error (including out-of-air, lost in cave/wreck when not trained, etc.)
• 25% - Medical (heart attack, etc.)
• 6% - Bad luck (wrong place wrong time, like one case where someone surfaced, gave an OK, and was then run over by a speeding boat)

I know that Capt. John Kades, the investigator I work most closely with at the LA County Coroner keeps some running stats just for LA County and he puts the "medical complications from diving" (which covers a slightly broad range) at 40%. This can also include include underlying medical conditions that perhaps didn't prompt the accident but factored into the cause of death.

Also note that I said "trigger" (part of DAN's 4-step analysis process). So if you run out of air (trigger) and then have a heart attack on the way up (medical), what ended up killing you? There's an art of interpretation to the science so nothing's generally carved in stone. Two people looking at the same data might come to different causes of death.
 

Attachments

  • DAN Fatalities Workshop Proceedings (April 2010).pdf
    3.4 MB · Views: 121
https://www.shearwater.com/products/peregrine/

Back
Top Bottom