Diver Death in Cayman

[fosterboxermom]

I thought Autopsy Reports were public domain. Can anyone with legal background clarify this?

Best Regards
Richard

Richard, I don't have a legal background but as far as I know it is up to the coroner to release the autopsy to the public. Most information gathered for an investigation is for the coroner such as statements, evidence, etc. This is what I was told. But that doesn't mean it needs to be broadcast on the Internet for all the people that don't want to do it justice just want to use it to satisfy some sick need to see.

 

[fosterboxermom]

I dont think anyone is looking for the full autopsy report. What some, including myself are interested in is this is truly a diving related death or a case of someone who died while diving. No one is looking to invade anyones privacy.

Well I think Garylee wants to post the whole autopsy report, you will have to ask him. If he wants to post the just the cause of death I have no problem with that. But the details of the report are not necessary.

 

[Eddie Kish]

Well I think Garylee wants to post the whole autopsy report, you will have to ask him. If he wants to post the just the cause of death I have no problem with that. But the details of the report are not necessary.

I agree 100% with you (and I believe most on this board would as well) There is no need for any info other than cause of death.

 

[Riger]

Another thing that I have meant to ask earlier;

What was Brendan's' Diving Insurance status?

Best Regards
Richard

 

[JonKranhouse]

This was posted before the thread was split and it's now orphaned on the "Divemaster Responsibilities" thread. The current conversation -- about publicizing an accident-report / autopsy -- makes this relevant. (Sorry for the width - I'll do better next time).

Much frustration has been expressed in this thread that the root causes of accidents are hardly ever learned by the public.
Clearly, lots of responsible people want to mitigate future accidents.
Maybe we should look to the past to determine a better way forward.

History of Accident / Incident Report Forms

In 1973, the dive industry adopted an accident reporting form that was 6-pages. The form was designed to find patterns, to mitigate future accidents.
MANY of the detailed questions / prompts have been eliminated on "modern" forms, by coordination between liability underwriters and training agencies.
Below are excerpts from the 6-page form.

In 1961 The Compressed Gas Association (CGA), began the "American National Standards on Underwater Safety," via the American National Standards Institute (ANSI).

Called the "Z86" project under ANSI, the Council for National Cooperation in Aquatics (CNCA) took over management of the Z86 project in 1968,
involving OVER SEVENTY separate organizations. Seven industry members and consultants created the "ANSI_Z-86.2-1973" Standard Underwater Accident Report Form,
drafted over a 4-year period and adopted in 1973 by the Z86 Underwater Safety Standards Committee.

ON FIRST PAGE OF THE 1973 Z86 FORM:
"...research completed has identified needed improvements in diving instruction, accident management
techniques, and equipment performance."

Please read the last line above, "To...improve the overall safety of diving"


30-years later, on PADI's Incident Reporting form (page 1):

...and again on page 3:

In 2009, a major insurance broker brags to the industry:
"Carol also revised incident reporting procedures to minimize information reported in order to reduce discovery of incident information."

But in the old days...
(Excerpts from the 1973 ANSI z86 form)

Specific call-outs prompt inputs vs. "modern" forms that only ask one single question, with little space for a response (e.g. "Surface Conditions"):

Specific questions RE buddy diving, and if the Coast Guard was notified (lacking on "modern" form):

Specific background RE swimming ability, and a "human factors" section (ENTIRELY missing on "modern" form):

Specific spots for itemizing equipment and condition of gear. But missing from this 1973 form:
Was air tested for CARBON MONOXIDE? If so, _______ ppm? (part-per-million).
And who had possession of the equipment after the accident?

Specific prompts to collect names and contact info for WITNESSES (entirely missing on "modern" form):

 

[Riger]

I am still convinced that there was a mis-interpretation underwater related to the location of divers and "buddy" groups.

Often times the person on one side of an underwater exchange is absolutely convinced of what the conversation was about and is absolutely wrong. I have personal experience in this matter and it is related to comms between my wife and I (under the water!! before anyone throws their penny into the pot).

We were a threesome buddy group inside the Thistlegorm wreck (Red Sea). About 20 minutes into the dive, my wife gets my attention, points to her computer, points to me and shows me the "shrugs with arms to the side" (***) signal. Because we both have AI computers and can see each others pressure I look at my pressure and show her the OK sign. She shakes her head and goes through the same routine with more aggression.. of course I still have no clue what she is talking about, I check her analogue pressure gauge, that looks good, so her air is ok.. I sign her that I am OK and challenge her if she is OK, she shows OK, and we will talk later.

Now I know I made some basic errors, I should have stopped looked at her computer taken the time to make sure that there was no other concerns etc....

At this point (to make my point) I could ask you all to guess what this was about, but that would reduce this discussion to a game-show.

What was the interaction about you ask? ... I am the geek and I set all her baseline settings on her computer for her (she does her own Nitrox % and MOD). She had an alarm going off, the cause of which, was not obvious to her and she was asking me what settings I had made to her computer! We have subsequently reset her computer and I guided her through all the settings and made her decide and set what she wanted.

The point I am making is ......

It seems that during the fatal dive, there were many opportunities for misunderstanding of communications between you and the DM/DG. Perhaps there was a genuine misunderstanding that caused him to think that there was no need for concern.

Once again, this is speculation, but sometimes the smallest of factors can have the worst result.

Best Regards
Richard

 

[Web Monkey]

Where do you dive? Have you ever been on a boat where the Capt and DM ask divers where THEY would like to dive that day?

I'm not sure if you're being sarcastic or not, but pretty much every boat I've been on has asked where we wanted to go.

Terry

 

[stevejaz]

I know I'm probably going to get crusafied for this...but..

Why is there no discussion that this guy made it to 346' and back to the surface in a period of 22 minutes? How do you get that deep accidently but still have the presence of mind to inflate your BC or somehow get back to the surface?

I'm certainly not blaming him for his own demise, but isn't the whole idea of this section of the board to understand what happened and to learn from it?

The DM has been crusified, maybe rightfully so (not for me to judge) but something went terribly wrong and this guy covered almost 700' verticle feet of water in one state or another and somehow initiated his return to the surface from 346'....HOW? I want to understand that! I'm a new diver, still working out bouyancy issues, but accidently making it to 346' and not knowing it? I know I'm beating this to death but I'm truely perplexed by this.

 

[Riger]

I know I'm probably going to get crusafied for this...but..

Why is there no discussion that this guy made it to 346' and back to the surface in a period of 22 minutes? How do you get that deep accidently but still have the presence of mind to inflate your BC or somehow get back to the surface?

Hi there, This was discussed about 800 posts back. There were 3 options if I recall, the two that come to mind were (1) self inflation of BCD and (2) positive buoyancy of an empty tank after being breathed empty.

Best Regards
Richard

 

[LeadTurn_SD]

I know I'm probably going to get crusafied for this...but..

Why is there no discussion that this guy made it to 346' and back to the surface in a period of 22 minutes? How do you get that deep accidently but still have the presence of mind to inflate your BC or somehow get back to the surface?

I'm certainly not blaming him for his own demise, but isn't the whole idea of this section of the board to understand what happened and to learn from it?

The DM has been crusified, maybe rightfully so (not for me to judge) but something went terribly wrong and this guy covered almost 700' verticle feet of water in one state or another and somehow initiated his return to the surface from 346'....HOW? I want to understand that! I'm a new diver, still working out bouyancy issues, but accidently making it to 346' and not knowing it? I know I'm beating this to death but I'm truely perplexed by this.

I can only guess, but to make it back up he would have had to hit the inflator button at some point to get positively bouyant. I would guess that at his max depth either narcosis or ox-tox would have rendered him unconscious... but perhaps not. I can't remember what the records are for deep air. Several of us commenting in this thread have been pretty deep on air, but not that deep.

But a brand new diver that deep... not sure what to think.

Anyway, he must have retained enough awareness to hit the inflator button at some point before blacking out, may have hit the inflator button then embolized on ascent.... all speculation on my part.

Best wishes.