Diver drowns in guided cenote dive

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mmmbelows

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Therein lies the rub.

Whether you're 1:1 or 4:1, unless the guide literally has eyes in the back of his head, a guide at the head of the line cannot possibly see anyone behind him/her. So that means they have to turn around to confirm everyone's there. How often should that be? Every 30 seconds? Every 10 seconds? Pick any time and you can still argue that a diver can get away unnoticed.

So hypothetically (JUST TO BE CLEAR, I'M NOT ADVOCATING THIS AS A REAL SOLUTION) let's put the guide at the BACK of the line so he/she can see everyone ahead of him/her. But now you've got a guest, possibly untrained in cave/cavern dives, leading the way. So that won't work.

Absent 1:1 side-by-side with the guideline in between them, there's not a good solution here. I know the few times I've done cenotes dives with one of my groups, I always take the rear position so the guide can lead and I can keep an eye on anyone who strays.

And maybe that's the answer. Require two guides for every uncertified group and have one at the front leading and one at the back watching for trouble.

- Ken

Unfortunately the answer when Mexico is in the topic is rules are bent and pushed to the limits in pursuit of profits. It's the way it always is. Cheerleaders can get upset about it, but there are plenty of examples and any of us with any decent amount of experience in Mexico all have the stories to prove it. There is no safe way for a cave guide to guide more than one non-cave certified divers in a cenote dive this death just proves it.
 

JohnnyC

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One of the problems is that "cavern zone" is so loosely defined in Mexico. And by that I mean they call whatever they want part of the cavern zone since quite a few "cavern" dives should easily be reclassified.

The fact is that cenote dives really do have an outstanding safety record, all things considered. If you look at the sheer volume of OW divers that pass through those systems without major incident, it really is pretty incredible.

We can make all the recommendations we'd like to see, but at the end of the day, it's Mexico, it's not going to change in any significant way, because Hans coming all the way from Germany on holiday still wants to do the dive and he's going to pay someone and they're going to take him, and the odds of anything actually happening are pretty damn infinitesimal. And then he's going to go to the beach and slather himself up with coconut oil and bake himself in the sun and eat lionfish tacos and go back to Stuttgart and tell all his friends how wonderful his holiday was. Because that is exactly what happens.
 

Germie

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For the situation of this topic I cannot say who did wrong, as I was not there and the cenote is unknown to me. But, I know a guide is not a cave instructor, but in my cave instructor course we have talked a lot about positioning as instructor. How do you turn your students when you are behind and they want to go further? And such things. Things that are not learned in a user cave course.
When I did my full cave course I already was dm. But where I then ready to guide caverndives? It will take time to get experienced in guiding people. And an experienced guide in ow can be unexperienced in caverns.
 
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BCSGratefulDiver

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Here's a map of the cenote in question. It's also known as the "Temple of Doom" ...

11703130_10154917910759815_2699905545601929762_n.jpg


... Bob (Grateful Diver)
 

John C. Ratliff

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Once again, we are speculating without much knowledge. We have someone saying that the tourist diver from Spain "strayed." Has anyone checked his equipment? It was stated that he "drowned." Was an autopsy performed, and was there water in his lungs? Or, could he have embolized on an emergency ascent? Did he run out of air? No mention was made of whether he had air in his tank. What was the depth? Did they go to the center of the Calvera cenote? Or, were they around the edges? Was there a potential medical problem, such as diabetes? Without knowing specifics, we really cannot say much about this death. As a safety professional with 30+ years of Professional Safety experience, I would heartily recommend re-reading Uncle Ricky's post about "blamestorming":

Accident analysis is the business of identifying mishap causes and recommending actions to prevent a repeat mishap.
Who's to blame doesn't matter.
The laying of blame, extraction of justice, punishment, liability, etc - all these are the business of the courts (and to satisfy our inner need for balance and justice in the universe), but they don't really address mishap prevention. Mishap prevention involves actions.
Example:
Lets say the causes of a mishap are all actions taken by a boat's captain.
Mishap analysis would identify those actions as causes, and recommend other actions that would prevent (or greatly reduce the chance of) the mishap in the future. Nothing about liability, fault, blame, punishment etc would be addressed in the mishap analysis because those are not actions that would prevent the mishap.
Example: "The boat didn't have enough fuel on board to conduct a search." might be identified as a cause of a mishap, and mishap analysis would recommend "that a boat always carry enough fuel to conduct a search" on every dive. Why the boat didn't have enough fuel, who made the decision to carry too little fuel, whose fault it is that the boat had too little fuel, etc, are all questions for regulators and courts, not mishap analysis. And it may be that there's no blame anyway - it could be that a new standard needs to be set because this mishap revealed a flaw in the current standard.
The general theme of mishap analysis is that all mishaps are preventable, even when no one is at fault. For example, all diving mishaps are preventable by not diving in the first place.
Mishap analysis doesn't waste time asking "what was he thinking?" either, but rather asks "what did he do?" We can agonize all day long about why Joe didn't ditch his weights when ditching his weights would have saved him, but it doesn't really matter. The action that will prevent a repeat of Joe's mishap is "ditch weights."
--
What we're trying to do in the A&I forum is to provide a forum for a Safety type analysis of mishaps; to identify actions that lead to mishaps and actions that can prevent mishaps. The mishap analysis mindset is difficult for those who lack formal training in it, as our natural tendencies are to find out who or what to blame and seek justice.
Just remember that justice isn't going to prevent future mishaps. It is changes in behavior that prevents recurrence of mishaps.
Rick
Mishap analysis & "Blamestorming"

SeaRat
 
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JohnnyC

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Realistically none of that matters unless there's something nefarious going on. We know how people die when they go cave diving.

We know he died IN the cave, so whether he strayed or not really doesn't matter. He entered the overhead and didn't come out. Whether it's because someone left him there and he couldn't get out, or he left the group of his own volition and couldn't get out, really doesn't matter until we get official statements. We know how to prevent that sort of thing, there are rules and regulations in place. We don't need to know the how or why he met his demise, it's irrelevant. Again there are procedures in place already. Doesn't mean people don't ignore those. It's like wiring code in a house. Just because there are building codes doesn't mean that Jethro the homeowner can't wire something up himself and burn his house down.

He shouldn't have embolized in the cave, he'd have to be in open water to get that great a pressure change in Calavera. Well, let me rephrase, as far as I remember about diving in the cave zone in Calavera, there was no depth change great enough to embolize. Doesn't mean I'm not misrememberating.

Drowning is always the cause of death in a diving accident where a medical emergency was not the cause of death underwater (if you're alive on the surface it throws all that out the window). Think about a rebreather diver, they dive with current limited cells, oxtox, and die. The cause of death is drowning, regardless of what circumstances led to it. If you die in a cave and it's not because you had a heart attack, the cause of death is drowning. Now usually it's because you got lost or run out of gas and couldn't get to the great big scuba tank called the sky, but the cause of death is still drowning, so it doesn't surprise me that the cause of death would be marked as such.

Accidents and incident analysis is fantastic for understanding things in order to prevent them happening again. However, in the case of cavern divers, the causes are clear, we know how to prevent them, we've even tried legislating safety in to the activity, but there are still people who ignore rules and regulations, and (very) occasionally it comes up snake eyes. As such, there's no analysis needed, we know what happened, he went beyond the level of his training and equipment and died. It's like Doc Deep, we all knew what was going to happen. It wasn't a surprise to anyone. When you enter the cave unprepared and ill equipped, it's much more surprising when you survive, than when you don't.
 

John C. Ratliff

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From what I can determine, a cenote is not a cave in the normal sense, and there are portions which are not overhead environments. We have only hearsay information, which is third-hand. A diver can embolize in less than 15 feet of water.

JohnnyC, look up "cenote" in Google Images. You will see kids snorkeling in some cenote(s) (darned auto check, I have to do weird things to write that word). These are caverns with open water under the opening. They do lead to caves, but it is not necessary to be in an overhead situation when diving in a cenote.

Now, about the reports; the tour leader has reason not to report things factually. That report cannot be trusted. In accident investigation, it is important to determine the facts of the case, to examine the equipment for problems or defects, to determine as much as possible the medical aspects (exactly how the person died) and make a determination as to the contributing factors (always plural) for the accident. For instance, did anyone check the tank for carbon monoxide?

What some do in this situation is take the "easy way," and blame either the diver or the guide for disobaying those rules or procedures that are in place for cave diving. When, in root causes analysis, we look at some of these situations, one technique is the Five Whys Analysis.
5 Whys - Wikipedia, the free encyclopedia
Determine The Root Cause: 5 Whys
Using Five Whys, you can ask why this diver "strayed" five times to get to some of the root causes of this accident.

Details are important! As Senior Master Sgt. Jerome Gorny (a USAF Pararescueman I knew quite some time ago) stated to me, "...attention to detail; get the details right and the jump will go right. Get one wrong, and things go bad quickly." (Actually, he was a bit more salty than that.). The same goes, I have found over the years, with accident investigation.

SeaRat
 
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JohnnyC

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From what I can determine, a cenote is not a cave in the normal sense, and there are portions which are not overhead environments. We have only hearsay information, which is third-hand. A diver can embolize in less than 15 feet of water.

JohnnyC, look up "cenote" in Google Images. You will see kids snorkeling in some cenote(s) (darned auto check, I have to do weird things to write that word). These are caverns with open water under the opening. They do lead to caves, but it is not necessary to be in an overhead situation when diving in a cenote.

Now, about the reports; the tour leader has reason not to report things factually. That report cannot be trusted. In accident investigation, it is important to determine the facts of the case, to examine the equipment for problems or defects, to determine as much as possible the medical aspects (exactly how the person died) and make a determination as to the contributing factors (always plural) for the accident. For instance, did anyone check the tank for carbon monoxide?

What some do in this situation is take the "easy way," and blame either the diver or the guide for disobaying those rules or procedures that are in place for cave diving. When, in root causes analysis, we look at some of these situations, one technique is the Five Whys Analysis.
5 Whys - Wikipedia, the free encyclopedia
Determine The Root Cause: 5 Whys
Using Five Whys, you can ask why this diver "strayed" five times to get to some of the root causes of this accident.

Details are important! As Senior Master Sgt. Jerome Gorny (a USAF Pararescueman I knew quite some time ago) stated to me, "...attention to detail; get the details right and the jump will go right. Get one wrong, and things go bad quickly." (Actually, he was a bit more salty than that.). The same goes, I have found over the years, with accident investigation.

SeaRat
I know what a cenote is. I'm a cave diver. I trained in Mexico. I have dived in Calavera. There is cave in Calavera. They found the body in the CAVE zone of the Calavera cenote beyond the reaper signs. The cave zone in Calavera at such a depth that embolizing while within the cave is so highly unlikely as to state that there would have to be serious extenuating circumstances, such as an already present lung over-expansion injury which would have prevented the dive in the first place. Other (cave) divers retrieved the body. Simply because their statements are not in the police report does not mean that they do not have the all of the information required to make an accurate estimation of the circumstances that lead to the divers death.

I know an awful lot about attention to detail. I'm a cave diver. I'm a rebreather diver. Detail is important in certain things. In this instance, detail is not important.

I know quite a few PJ's too (and fighter pilots, and weps guys, and TACP's, and all sorts of people who live and die by attention to details). If a PJ jumps out of a plane and never pulls his chute, he's dead because of the sudden stop. There may be reasons he did not deploy his chute, but aside from a medical event during freefall, it's still the stop that kills him. This is literally exactly the same thing, except it's drowning instead of the sudden deceleration. And in this case, there's nothing NEW to learn about how not to die in a cave. (And let's not get into semantics, if you start talking about AAD's not firing I'm hitting ignore.)

We don't need to analyze this most current diver death. We know all we need to know, he went into the cave, he was not trained, he did not have the right equipment, he died. What you want to do is assign blame (ironically you quote a post about "blamestorming") but you want to disguise it as "analysis."

I get the feeling that you're not a cave diver, not familiar with diving in Mexico, definitely not familiar with Calavera, and whatever "Professional Safety" experience you have, it has very little to do with cave diving, and thus in this case, irrelevant.
 
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The Chairman

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We know all we need to know, he went into the cave, he was not trained, he did not have the right equipment, he died.
Bingo, Yahtzee, we have a winner!
From what I can determine, a cenote is not a cave in the normal sense,
While they may be marketed a bit differently, a Cenote is a well or Spring fed by an underground river, just like we have here in Florida. That you see it differently at all is the real problem. They are just as deceptive and will kill the untrained just as easily as diving into the cave zones of a Florida Spring.

 
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