Coroners Report. What do you think!

[kmarks]

I think you misunderstood some of my comments

• "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.

I don't think that most divers who's lifeless bodies are found with the weights didn't drop their weights because actually dropping them wasn't something they had ever practiced. We do practice pulling weights and putting them back in without dropping them both at the surface and underwater. There is no value in making a DM, instructor, or some other sucker practice their search and rescue skills to recover dropped belts and pouches. I do that enough when students don't firmly click their pouches into place.

• "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.

I apologize for the cheap shot, but you say that if you can't figure out a more exact cause of death, you just called it drowning. So my wording was rude, but my intent was true, even if exaggerated.

• "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 don't think anyone ever died of narcosis, just like no one every died from a strange mole. Skin cancer kills because it metastasizes and causes tumors elsewhere. Narcosis can be a contributing factor to a drowning because it causes irrational behavior like going deeper, ignoring your gauges, and taking your reg out for no good reason. And even if it happens in 30 feet of water, where narcosis is not a factor, an out of air diver doesn't forget to drop the weights because they didn't want to, it's probably because they are panicking and forgot to follow the checklist. Panic is a complete shut down of rational thinking. If your reg isn't working, panic will tell you to spit it out. Panic will tell you to take a big breath. Panic won't say "Hey, remember those weights?" Experience tells you that. And it takes a lot more experience than AOW and 50 dives for some people.

 

[boulderjohn]

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.

That's the study I cited that listed that cited air embolism following a rapid ascent to the surface. The primary reason for that rapid ascent (triggering event) was usually out of air. Following that study, new PADI standards were added to improve use of the buddy system and improve monitoring of air. They also added weight system dropping at the surface.

But being out of air does not necessitate dropping weights. Note that in the air embolism cases, the divers made it to the surface with ease--too much ease, in fact. Standard training for low on air/out of air incidents has the first choice being a normal ascent, second choice being sharing air with a buddy, doing a CESA as a third choice, and a buoyant ascent (dropping weights) as the fourth and last choice. The general idea of that final choice is that you only drop weights if you have reason to believe you may not make it to the surface with a normal ascent or a CESA. In the overwhelming majority of those situations, an out of air diver beginning to ascend will almost immediately become positively buoyant because of expanding air in the BCD and will ascend with increasing rapidity to the surface, even if weights are not dropped.

What I saw personally in one case and I saw in a widely misunderstood video on ScubaBoard is a diver neutrally buoyant with a thick wetsuit at depth starting to ascend, but doing so using a technique that is wrongly taught by many instructors who only know warm water/thin wetsuit diving. These instructors wrongly teach students to dump all their air in the BCD before beginning the ascent. With a thick wetsuit, divers have no choice but to be overweighted at depth, and the diver may have too much weight to ascend. If the diver does not replace the air in the BCD quickly, the diver will start to descend and then potentially panic (which you see on that ScubaBoard video).

 

[Edward3c]

The BSAC practice routine is to jettison the weight belt in a maximum depth of 1m.

 

[Ken Kurtis]

In LA County, we were very fortunate in 2019 that we had ZERO scuba fatalities. (We've already had four or five this year.) In 2016, we had 6 fatalities. Whether or not they're representative of the overall picture, here's what the cause of death in each was:

#1 - Deferred (this is not unusual and by now the case has been closed with a COD but I don't have it in my records) - Victim was known risk-taker, wore 38 lbs lead, liked to dive very deep, 0.028% blood alcohol, 30% occlusion artery, enlarged/fatty liver
#2 - Heart attack following a lobster dive with a scooter
#3 - Drowning (free-diver) - Wore 30 lbs weight, family said in excellent health, blood alcohol 0.049%
#4 - Deferred - New diver (first dives after cert - cert was two months prior), passed out a few minutes into dive at 40-50 feet, 2600psi in tank, unclear if autopsy was performed
#5 - Deferred - Training dive with instructor, bolted to surface at end of dive in current, passed out on current line
#6 - Drowning - Looking for lobster, went inside pipeline (wearing doubles), did not come out, no air in tanks, found 500 feet inside pipe, 15-20 lobsters in bag (daily limit in CA is 7)

And here are 4 from 2017:
#1 - Drowning/barotrauma - 1700 dives, became inverted and over-inflated in drysuit but was still negative, buddy assisted but she passed out, he brought her rapidly to the surface, CPR administered & AED used, never regained pulse, autopsy showed severe barotrauma with air trapped in lungs/brain/skin
#2 - Drowning/embolism - Found unresponsive on bottom during tech dive to 190', others on dive "sent her up" because they needed to deco, she was spotted and brought on board boat, autopsy revealed subcutaneous emphysema and other sings of barotrauma
#3 - Heart attack - Looking for lobster, wearing 40 lbs lead (est to be 20+ more than needed), made it to surface but coughing loudly, private boat nearby took him aboard and he passed out, history of cardiac issues
#4 - Drowning with underlying cardiac issues - Diving for scallops on oil rigs (rig is in 300 feet of water - dive took place around 100 feet), observed passed out underwater and slowly descending, rescue attempted but aborted at 160 feet, victim recovered next day by Sheriff's dive team at 265 feet, main cylinder was full but pony bottle was empty, may have confused pony reg for main reg and couldn't switch back when OOA

So there you have 10. 2 heart attacks, 2 with measurable alcohol in system, 2 grossly over-weighted, a new diver, a highly-experienced diver, 5 drowning, 4 that I'd term "diver error," and plenty of underlying medical issues.

 

[Ken Kurtis]

But being out of air does not necessitate dropping weights.

One technique I teach - and I think someone mentioned it here - is that if you think the sh*t has hit the fan remove your weights (belt or weight pockets) but hold them in your hold while you try to get to the surface. This will allow for a more controlled ascent and, if you should lose consciousness, the weights will fall from your hands and you'll end up (unconscious) on the surface where you have a much better chance of being saved than if you're on the bottom.

 

[divezonescuba]

These instructors wrongly teach students to dump all their air in the BCD before beginning the ascent.

Sadly, this appears to be common in the Caribbean and even the U.S. Just heard it a month ago in FL.

The other one is crew telling divers to hand up their fins while they are still in the water.

 

[lowwall]

The coroner's report is mostly reasonable given the specifics of this incident

The victim had demonstrated very poor skills including an inability to control her bouyancy. It's very likely that Ms. Lee went OOA on the ascent at around 15m/50'. Ditching weight at that point is obviously not ideal, but it might well have been the last option to save her life. Apparently a CESA was beyond her abilities, and given her lack of basic skills, manually inflating her BCD was probably a nonstarter. It's very easy to imagine her sinking while frantically pushing the buttons on her inflator.

The SMB (actually DSMB) suggestion was not reasonable. Here's the relevant section of the discussion

"Although Dive Victoria dropped shot lines at both dive sites, the lines were not used by [the victim and her buddy] during the ascent... In the event they do not ascend on the shot line, divers should deploy a [DSMB] during their ascent. This would give notice of their location and assist in any rescue efforts."

This suggests a lack of understanding of when a DSMB is deployed and how it is used. I think the discussion of shot lines at the hearing probably led to this confusion. To be clear, SMBs can assist in the rescue of drifting or lost divers. They are not attached to the diver, so they can't help you find or recover an unconscious or deceased diver if there is any current or wind. They are also normally deployed at the safety stop or at the start of an ascent from relatively shallow water. It would not be normal practice to deploy one at 30m.

The larger issue was correctly identified by the coroner: the victim's appalling lack of basic skills despite her having gone through both OW and AOW courses. The coroner suggests "periodic assessment of qualified SCUBA divers" would be helpful. While that may be true, in this case it appears that the initial assessment was the real problem. The victim should not have been granted at least the AOW certification.

 

[Celt]

She made an uncontrolled accent on the first dive. It was her first time to 35 meters on the second dive when she accidentally dropped to the seabed.
She made it back to 14 meters of the surface and then sank to the wreck and was eaten after drowning, very sad. Any amount of changes could have saved her but it’s easy to be wise on hindsight.

 

[boulderjohn]

I have to wonder how much of her training and experience included 7mm wetsuits. If you are not accustomed to them, they can be tricky. When I have conducted OW training dives in my area, the students were going from 3mm suits in the pool to 7mm suits in the open water, and I spent a lot of time talking with them about two specific issues they would need to get used to.

1. When they ascend, in the last 15-20 feet, the suit becomes much more buoyant, and it does so rapidly. If you are not ready for it, it can take you to the surface like a rocket. (The victim, wearing a 7mm suit, missed her safety stop and rocketed to the surface on her first dive. She promised not to do it again, and demonstrated her control of the deflater button on her BCD.)
2. When dumping air from the BCD during an ascent, you must do it gradually and carefully. When diving with a 7mm suit, you have no choice but to be overweighted at depth because you need that weight in shallow water. If you dump all your air at once, you may be overweighted enough to descend rapidly. (The victim promised everyone that on this ascent, she would be ready to dump air once they got near the safety stop depth.

 

[Storker]

The BSAC practice routine is to jettison the weight belt in a maximum depth of 1m.

On occasions, I like to practice ditching my weights. I do that on a shore dive, in a place where I can stand up if I want to, but deep enough that I can pretend that I'm over deep water. Basically roughly 1m of water below me. And I always do that exercise on the surface, because I believe that that's where it's most probable that ditching might be a good idea.

It has occasionally been... enlightening. Tinker enough with your gear, and your muscle memory will remember wrong. Which could be somewhat awkward if SHTF.