Death of a recreational diver after a fall on board MV Elaine

[KenGordon]

Most of the BSAC reports have a summary of some sort. Typically it will be “like last year, most of these accidents would have been avoided if the people involved had followed their training”. Sometimes something new turns up, maybe medical as recently, but the tune isn’t changing.

So, the lesson for everyone, is follow your training. That might have not helped the bloke in this case, unless his training included “be sensible”. Of course technical training does include having the appropriate attitude.

I have fallen over on a boat like this one. I thought I was extremely lucky not to smash my head open.

 

[Gareth J]

Most of the BSAC reports have a summary of some sort. Typically it will be “like last year, most of these accidents would have been avoided if the people involved had followed their training”. Sometimes something new turns up, maybe medical as recently, but the tune isn’t changing.

So, the lesson for everyone, is follow your training. That might have not helped the bloke in this case, unless his training included “be sensible”. Of course technical training does include having the appropriate attitude.

Over the years, as a result of the analysis of the incident report, the training has been modified. Two elements that immediately come to mind are
1. The removal of buddy breathing from the training syllabus, and the emphasis on the use of AS (Alternate Source, or Octopus). This was as a result of the number of fatalities when air sharing (buddy breathing) in the event of a buddy running out of gas.
2. The positive exercise of dropping your and/or the casualties weight belt during rescue training. As a result of the number of divers that sank to the bottom after reaching the surface or having been brought to the surface in an emergency.

I have fallen over on a boat like this one. I thought I was extremely lucky not to smash my head open.

I had a regular dive buddy for a long time that amused many of us (despite his lack of a sense of humour).
He had originally enjoyed Sea Fishing (with a rod and line). He gave this up, two particular reasons.
1. Falling over on the deck of pitching boats - he had knocked himself out on more than one occasion.
(This amused me, knowing the story, watching him walk around on deck in full dive kit).
2. He suffered extreme sea sickness. - which was the primary reason he stoped fishing!
- On the back of that where his two solutions to sea sickness
a/ Eat Custard Creams (a British Biscuit), the reason, they taste the same coming up as they did going down.
b/ In a bad sea, he was the first in, and last out, even if the vis' was awful, and there was nothing but flat sand to look at.
(It minimised his period of sea sickness, he was ok in the water.)

 

[SapphireMind]

I am sure you meant this, but it also means designing a system that minimizes the most likely reasons for errors.

This is actually a major issue in threads on ScubaBoard. In analyzing a diving fatality, many people will point out a mistake the diver made and dismiss it as a case of diver error, totally discounting the fact that a simple change in the system would have made that error much less likely.

An example of this from the world of aviation. An analysis of a number of common pilot errors leading to crashes occurred because two controls doing the opposite things were placed side-by-side on the control panel. Moving them apart virtually eliminated a common and deadly error.

Exactly. That's the whole point - everyone makes mistakes. Now there are some glaring errors that can't be corrected for (someone, untrained, going into an overhead situation on purpose without help or knowledge of others despite knowing the warnings and risks) but other errors everyone is likely to make at least once, and the goal is to have a system in place to prevent those from being catastrophic.

Diving I can see it being harder to institute systems, because so much falls onto the diver and there aren't teams of people doing things that affect one another, but that doesn't mean it's not possible at all.

I think this case is difficult because after an initial injury, it can be hard to know the extent of the injuries because your body has been flooded with adrenaline, which masks pain. I was hit by a car once, and it was very hard for me (and likely scary to the witnesses) to stay still in the immediate aftermath as I assessed myself and really waited to make sure it was safe to change positions. (I was fine )

Complacency is every diver's biggest enemy I think and it's hard to compensate for that. I like to read accident reports and think of all the ways I could die prior to going into the water, but that's not everyone's cup of tea

 

[boulderjohn]

I was hit by a car once, and it was very hard for me (and likely scary to the witnesses) to stay still in the immediate aftermath as I assessed myself and really waited to make sure it was safe to change positions.

Yes.

I was in a bicycle accident a few years ago when a teen bicyclist turned a blind corner on the wrong side of the bike path at high speed and ran into me. When the ambulance arrived, they took one look at the screaming teen and one look at me lying calmly on the ground and went to work splinting the screaming teen's broken arm, even though between his screams he told them that I was hurt worse then he and should be treated first. They apparently didn't believe him.

Once they had him on the way to the ambulance, they asked me about my injuries. (No, they did not ask me anything except my name and date of birth until they had carted him off.) It turned out my self-diagnosis was correct. I had a shattered collarbone, several broken ribs (front and back), a broken hand, and a partially collapsed lung. (Yes, I told them all that.) It turned out later that they didn't believe me--I was too calm. They asked me to get up and walk with them to the ambulance. I insisted that they put my arm with the shattered collarbone in a sling first, and they finally agreed to that much treatment. After I reached the ambulance, they had me climb in on my own and sit on a jump seat behind the driver while they ministered to the teen with the broken arm in the stretcher. We then drove off to the hospital together, where they carried the boy with the broken arm into the emergency room and asked me to walk in on my own.

So, yes, diagnosing an injury can be difficult if the injury is serious enough to put the injured person into shock. the funny thing is, that was part of the standard Boy Scout first aid merit badge course I taught a half century ago, and it is part of the standard first aid course I teach now. It is apparently not a part of the training for ambulance staff.

 

[fsardone]

Iwent through training with the italian red cross. The screaming injuries are to be treated later unless bleeding to death: no shock and are breathing the pale immoble and silent one are of concern...

 

[SapphireMind]

Yes.

So, yes, diagnosing an injury can be difficult if the injury is serious enough to put the injured person into shock. the funny thing is, that was part of the standard Boy Scout first aid merit badge course I taught a half century ago, and it is part of the standard first aid course I teach now. It is apparently not a part of the training for ambulance staff.

Wow, terrible ambulance crew! I'm glad you are ok. They should definitely have been more concerned about the quiet person. Even without true "shock", unless the quiet person is moving freely, coherent and oriented, they should be of high concern.

I can easily see that between the embarrassment of having fallen, the eagerness to not miss the dive opportunity/try and keep up, it would be easy to overlook more minor injuries that might cause issues at depth. I am definitely one to err on the conservative side and say a true fall with full gear would probably cause me to call the dive, but I know many people aren't me, and don't have the accident-prone issues I do. (but so far, I'm immortal, proven by the fact I've never died )

I've been trying to think of systems things you could implement, but it's difficult with diving, especially when you consider it is going across different countries.

 

[KenGordon]

I've been trying to think of systems things you could implement, but it's difficult with diving, especially when you consider it is going across different countries.

This is an exceptional case. It isn’t the most useful one from a systems point of view. We can take “be sensible” away from it. In the training I give there is a theory lesson about what can go wrong and how not deal with it. The number one way to deal with a problem is not to have it in the first place, many incidents start before anyone gets wet - the plan to too much, there isn’t no plan, kit is slightly broken, gas is not analysed, people are not practiced that sort of thing. This is a useful example of those and helpful to encourage a “anyone can call the dive/better to dive another day” attitude.

Other questions arise (and I suppose the child’s lawyers will be looking at these) regarding operation of the boat and whether what they did contributed. U.K. dive boats treat everyone as an adult who is responsible for themselves (and buddy/group as appropriate). They are not inclined to voice an opinion about the diving. I am not at all surprised they didn’t stop him going in. Whether the layout or weather mattered I don’t know but you can imagine better or worse conditions making a difference. More important is the peer group of divers on the boat. A culture of calling it vs a culture of pressing on definitely makes a difference. Very often divers at this level are self described “big boys” and more inclined to the later.

And of course, maybe the diving bit made no difference once he’d had the fall. Keeping work spaces and places the public can go in a place of work safe is not a new idea.

 

[wgw04024]

This is an unfortunate story, but man, lawsuits these days.

 

[caruso]

This is an unfortunate story, but man, lawsuits these days.

These days? It's always been that way especially in jurisdictions that do nothing to stop it. I was listening to Harry Chapin "Taxi" the other day on the radio, I remembered when I saw him perform at my college during freshman year, and that he had died unexpectedly. I refreshed my memory with an internet search. He was in a car accident on a major highway- witness saw him put on his flashers, slow way down, then he swerved right, and then left, directly into the path of a tractor trailer that couldn't avoid him. Big crash, big fire, the truck driver and a witness pulled him out but he suffered a fatal injury to a major blood vessel and bled out before he got to the hospital. It was determined he either had a medical issue or a mechanical issue or maybe both but it was never confirmed one way or the other.

His widow sued the tractor trailer company for negligence and won $7 million bucks.

 

[Bubblesong]

These days? It's always been that way especially in jurisdictions that do nothing to stop it. I was listening to Harry Chapin "Taxi" the other day on the radio, I remembered when I saw him perform at my college during freshman year, and that he had died unexpectedly. I refreshed my memory with an internet search. He was in a car accident on a major highway- witness saw him put on his flashers, slow way down, then he swerved right, and then left, directly into the path of a tractor trailer that couldn't avoid him. Big crash, big fire, the truck driver and a witness pulled him out but he suffered a fatal injury to a major blood vessel and bled out before he got to the hospital. It was determined he either had a medical issue or a mechanical issue or maybe both but it was never confirmed one way or the other.

His widow sued the tractor trailer company for negligence and won $7 million bucks.

Harry Chapin was found 40% negligent and the truck driver was found 60% negligent by the witness accounts. The loss of future earnings, which they base the award on, was about 12 million, and the widow got a 60% of that amount. The story that I heard, (as a kid), is that the truck was going too fast to stop safely for the distance, and the truck actually jack knifed into his car. I tell my kids, never drive right behind or in front of an 18 wheeler, or even a pickup with a load in back. "If you can't see the trucks side mirrors, they can't see you" is another popular bit of wisdom.