Diver missing on Vandenberg - Florida

[KevinNM]

Is the buddy system failing really the root cause of the missing diver? The failure of the buddy system certainly has something to do with this, but I doubt that caused him to decide to suddenly ascend, which seems to be deeply involved with this incident.

 

[Saltyhawg]

I think what is being said is the failure of the buddy system is the reason he is missing. Whether and how much it contributed to his demise is still in question.

 

[Steve_C]

I think what is being said is the failure of the buddy system is the reason he is missing.

Maybe, Maybe not. If I am at 100 ft part way through the dive and my buddy suddenly goes shooting for the surface into an area with currents I am not going to shoot up after him. I am aborting the dive. If for no other reason then the boat if it picks him up will need to head for medical care. Even if I do a controlled ascent there is a good chance I will not arrive anywhere close to him. If said buddy then descends again, for whatever reason, while I with the rest are making a safe ascent up the line, then he/she is missing.

Not sure I would call diver panic a failure of the buddy system.

Not saying this is exactly what happened, but it is one plausible scenario. You do not stare at your buddy every second of a dive. You also look around.

 

[bowlofpetunias]

The red herring is not the qualifications. Diving below their 60 foot qualification to 95 feet is quite relevant for A&I. A diver is responsible to dive within his qualifications. If these divers were OW (and new), and diving below 60 feet, they should have been wary of adding swim throughs and other complications to a dive that was already beyond their training. Its a good A&I learning point for new divers to ask questions of the dive op before they splash and ensure the DM/guide won't put them in a position they aren't adequately trained to respond to.

As for the red herring, you'll find that in an over weighting discussion. Any root cause analysis begins with a problem statement. In this accident, the problem is that a diver is missing. Why is a diver missing? Because no one was with him when he disappeared. Why wasn't anyone with him when he disappeared? Because his buddy left him on the wreck. Why did his buddy leave him on the wreck? Because the buddy system on this dive was not effective. Why wasn't the buddy system effective? Answer this and you have the root cause for the missing diver, and it isn't going to have anything to do with weighting, more likely an insta-buddy issue.

Weighting, skill set, current, etc. are all contributing factors. The victim may not have survived the dive due to one or more of the contributing factors, but he would not be missing if his buddy was with him throughout the dive.

My "Red Herring" referred to discussion of the Qualifications of the Witness. He seems to have been buddied with the DM or that was his understanding. There has been no indication that his qualifications or actions contributed to the accident ocurring to somone who was not his buddy. The qualifications and experience of the missing diver is significant tho. We have no idea what they were.

I agree with your cause and effect process as a reasonable path to follow. The truth is that more often there are a chain of events and factors that escalate to become the accident. That is why discussion in A & I are valuable we examine many possible contributors.

Here is another potential flow using your system.

Why is a diver missing? Because he was too stressed to follow his buddy into the wreck. Why was he too stressed to follow his buddy into the wreck? Because because he was having trouble with his bouyancy. Why was he having trouble with his bouyancy? Because he was overweighted. Why was he overweighted? Answer this and you have the root cause for the missing diver.

Another approach.

Why is a diver missing? Because he didn't follow his buddy into the wreck. Why didn't he follow his buddy into the wreck? Because he was too stressed. Why was he too stressed? When he looked into the hole he remembered his instructor told him he should never go into an overhead environment or he would die. What happened after he decided not to enter the wreck. He was too stressed on being alone and decided to abort the dive. Why did he decide the best choice was to abort the dive? Answer this and you have the root cause for the missing diver.

IMHO it is too easy and simplistic to blame buddy separation or training for Accidents. We often have no idea if a buddy in arm's reach would have changed anything. As Steve_C said so well... a buddy can only do so much...

The purpose of A & I is to examine all potential contributors to the event and hopefully help divers avoid or learn how to mitigate them to become safer divers.

 

[Abdullah]

My "Red Herring" referred to discussion of the Qualifications of the Witness. He seems to have been buddied with the DM or that was his understanding. There has been no indication that his qualifications or actions contributed to the accident ocurring to somone who was not his buddy. The qualifications and experience of the missing diver is significant tho. We have no idea what they were.

I agree with your cause and effect process as a reasonable path to follow. The truth is that more often there are a chain of events and factors that escalate to become the accident. That is why discussion in A & I are valuable we examine many possible contributors.

Here is another potential flow using your system.

Why is a diver missing? Because he was too stressed to follow his buddy into the wreck. Why was he too stressed to follow his buddy into the wreck? Because because he was having trouble with his bouyancy. Why was he having trouble with his bouyancy? Because he was overweighted. Why was he overweighted? Answer this and you have the root cause for the missing diver.

Another approach.

Why is a diver missing? Because he didn't follow his buddy into the wreck. Why didn't he follow his buddy into the wreck? Because he was too stressed. Why was he too stressed? When he looked into the hole he remembered his instructor told him he should never go into an overhead environment or he would die. What happened after he decided not to enter the wreck. He was too stressed on being alone and decided to abort the dive. Why did he decide the best choice was to abort the dive? Answer this and you have the root cause for the missing diver.

IMHO it is too easy and simplistic to blame buddy separation or training for Accidents. We often have no idea if a buddy in arm's reach would have changed anything. As Steve_C said so well... a buddy can only do so much...

The purpose of A & I is to examine all potential contributors to the event and hopefully help divers avoid or learn how to mitigate them to become safer divers.

Your analysis relies on facts not in evidence and seems to be looking to avoid particular outcome. We don't know the victim was stressed about entering the wreck. We do know the victim is missing. And we know the victims' buddy did not stay with the victim. Analyzing the facts, not the speculation, leads back to buddy separation.

The witness didn't sound entirely sure who his buddy was, which is evidence that the buddy system was not effective on this dive. Had the victim's' buddy stayed with the victim he may not have been able to save his life, but then the victim would be dead, not missing and presumed dead. On the other hand, the problem may have been something the buddy team could have worked out, but we can never know that because the buddy team split up and the opportunity for a successful intervention was lost.

The A&I lesson learned is to stay with your buddy: Before you splash, identify clearly who your buddy is, plan the dive, decide what the buddy team will/won't do on the dive, review hand signals, and perform pre-dive safety checks. It's OK to sort out the dive with your new buddy before you splash. If your insta-buddy is uncomfortable with that, get another buddy.

 

[Pinecube]

Why wasn't anyone with him when he disappeared? Because his buddy left him on the wreck. Why did his buddy leave him on the wreck? Because the buddy system on this dive was not effective.

I'm an OW diver with about a dozen dives, so take my comments for what they're worth. However, I don't see how an accident can be blamed on any one 'root cause'. From what I've gathered, a number of 'red flags' have compounded up to the point that created the accident. For the sake of an example, lets say he had a buddy, but developed an equipment problem... Perhaps a buddy may have been able to help had they seen something happen in front of them, but the swim-through hole was just wide enough for one person. So my question is, since one person has to go through first, is it even possible to maintain the buddy system on a swim-through? The buddy in the rear is always going to be invisible to his buddy if even for a short time.

On dives around shipwrecks, I've often looked into the wreck (from the outside) and tried to think of problems that you could run into in wreck penetrations. Getting hooked on a nail or a piece of metal, current changing while you're inside, stirring up silt... I find it a little shocking that I hadn't even considered how you see your buddy, or for that matter how you communicate with your buddy or another diver that might be in the wreck. If nothing else, this accident is driving home for me the need for proper training even for "simple" swim-throughs and that the more I think about it, the more I respect I have for what wreck/cave divers do.

 

[bowlofpetunias]

I'm an OW diver with about a dozen dives, so take my comments for what they're worth. However, I don't see how an accident can be blamed on any one 'root cause'. From what I've gathered, a number of 'red flags' have compounded up to the point that created the accident. For the sake of an example, lets say he had a buddy, but developed an equipment problem... Perhaps a buddy may have been able to help had they seen something happen in front of them, but the swim-through hole was just wide enough for one person. So my question is, since one person has to go through first, is it even possible to maintain the buddy system on a swim-through? The buddy in the rear is always going to be invisible to his buddy if even for a short time.

As Wookie pointed out I AM trying hard to keep this thread on topic! Please can we end the hijack about what PADI or other agencies say about overheads. The topic of the witness's training is also off topic since we have no indication that it contributed to the accident.

Bold added to the partial quote of Pinecube. You are right on here. That is what I was trying to get at. In another thread TSandM referred to The Incident Pit. Each step you take in (each contributing error) brings you closer to the point where you can not recover.

My Opinion is also that picking any one root cause is too simplistic. Buddy separation is one of the things most often pointed to as the cause of accidents. Even the best buddy in arm's reach can only do so much. Training is something else that is often point to as the cause of accidents. Again too simplistic IMHO even the best training and instructor can not guarantee that the diver will continue to follow their training! You just can't blame the instructor/agency if someone is irresponsible! Too easy to point to medical problems.. no post mortum so no way to know. Equipment failure another commonly used cause we can't prove or disprove with no equipment recovered.

Yes the problem seems pretty clear. Missing diver and dare I say a deceased diver

My Theory which seems consistent with the Witness statement is that the diver for some reason chose not to enter the wreck. If he had entered the wreck and got into trouble he would have been found in the wreck.

According the the witness, at some point suspected he was overweighted. One needs to exercise caution on concluding this as the witness stated he (the witness) is not a terribly experienced diver.

Stress often clouds judgement and escalates into panic. It seems that some present felt that the diver "bolted for the surface". This would seem to indicate poor decision making which may be a result of stress escalating into panic.

Clearly there was nobody with him to help him get whatever was going on under enough control to reverse it. This is where buddy separation comes in. It does seem that buddy separation was inevitable according to the dive brief. Whoever was last in line was going to be out of view of everyone else while in the wreck.

Finally one might assume that the diver was undertaking a dive he was not prepared to do. It is unclear if this was due to inadequate training, experience, equipment, medical condition, failure of dive brief or attitude.

Putting all those factors together may wind up being what took this diver so far into the incident pit that he could not escape.


Disclaimer while I may be using information submitted in this thread to create a POTENTIAL explanation I was not there so it can only be speculation. I may be totally and completely wrong... it has been known to happen!:blush:

The diver entered the water unclear about specific dive buddy assignments. On descent the diver discovered he was over weight but was managing to control his bouyancy. At the entry point of the wreck the diver declined to enter possibly due to discomfort regarding weighting and concern about maintaining bouyancy control in the confined area with potential for entanglement.

Left alone with nothing else to think about the stress escalated to the point the diver decided to abort the dive. In the process of aborting the dive further bouyancy issues arose resulting in higher consumption of breathing gas. Struggling to the surface the diver failed to drop weights (weights were not reported to be found at the site) and was unable to maintain control on the surface and sank. With nobody close enough to assist he drown and being overweighted started sinking..... resulting in a missing diver.

 

[Abdullah]

As Wookie pointed out I AM trying hard to keep this thread on topic! Please can we end the hijack about what PADI or other agencies say about overheads. The topic of the witness's training is also off topic since we have no indication that it contributed to the accident.

Bold added to the partial quote of Pinecube. You are right on here. That is what I was trying to get at. In another thread TSandM referred to The Incident Pit. Each step you take in (each contributing error) brings you closer to the point where you can not recover.

My Opinion is also that picking any one root cause is too simplistic. Buddy separation is one of the things most often pointed to as the cause of accidents. Even the best buddy in arm's reach can only do so much. Training is something else that is often point to as the cause of accidents. Again too simplistic IMHO even the best training and instructor can not guarantee that the diver will continue to follow their training! You just can't blame the instructor/agency if someone is irresponsible! Too easy to point to medical problems.. no post mortum so no way to know. Equipment failure another commonly used cause we can't prove or disprove with no equipment recovered.

Yes the problem seems pretty clear. Missing diver and dare I say a deceased diver

My Theory which seems consistent with the Witness statement is that the diver for some reason chose not to enter the wreck. If he had entered the wreck and got into trouble he would have been found in the wreck.

According the the witness, at some point suspected he was overweighted. One needs to exercise caution on concluding this as the witness stated he (the witness) is not a terribly experienced diver.

Stress often clouds judgement and escalates into panic. It seems that some present felt that the diver "bolted for the surface". This would seem to indicate poor decision making which may be a result of stress escalating into panic.

Clearly there was nobody with him to help him get whatever was going on under enough control to reverse it. This is where buddy separation comes in. It does seem that buddy separation was inevitable according to the dive brief. Whoever was last in line was going to be out of view of everyone else while in the wreck.

Finally one might assume that the diver was undertaking a dive he was not prepared to do. It is unclear if this was due to inadequate training, experience, equipment, medical condition, failure of dive brief or attitude.

Putting all those factors together may wind up being what took this diver so far into the incident pit that he could not escape.


Disclaimer while I may be using information submitted in this thread to create a POTENTIAL explanation I was not there so it can only be speculation. I may be totally and completely wrong... it has been known to happen!:blush:

The diver entered the water unclear about specific dive buddy assignments. On descent the diver discovered he was over weight but was managing to control his bouyancy. At the entry point of the wreck the diver declined to enter possibly due to discomfort regarding weighting and concern about maintaining bouyancy control in the confined area with potential for entanglement.

Left alone with nothing else to think about the stress escalated to the point the diver decided to abort the dive. In the process of aborting the dive further bouyancy issues arose resulting in higher consumption of breathing gas. Struggling to the surface the diver failed to drop weights (weights were not reported to be found at the site) and was unable to maintain control on the surface and sank. With nobody close enough to assist he drown and being overweighted started sinking..... resulting in a missing diver.

Your speculation certainly is creative, but does ignore the facts of this incident. Let's try to frame this thread by what we know occurred, not by what we would like to have occurred. While many people on SB do tire of the "buddy did it" discussion, in this case it is particularly relevant because the witness is reporting that none of the standard buddy system processes were followed before or during the dive.

Distilling an accident down to the root cause is supposed to be simplistic. The isolation of the process failure that triggered the event is different than listing all the things that may have escalated the event. The key phrase here is process failure. We are all trained on a recreational diving process that starts with pre-dive planning. During every standard pre-dive plan the divers determine how they will conduct the dive. If there will be no buddy teams, it is so stated in the pre-dive plan. If there are supposed to be buddies, the pairs lock up and agree on how to conduct the dive. If the victim doesn't want to do swim throughs, he so states at this point. Plan the dive, dive the plan.

The process failure we can identify based on statements from the witness is that the pre-dive planning did not adequately define the buddy assignments or their individual roles or desires for the dive. Once the failure cascade began for the victim during the dive, there was no one present to intervene because there was no one assigned to be present to intervene during the pre-dive planning phase. No one assigned, no one watching, no one looking back in the wreck to make sure his buddy was still behind him.

Rather than speculating on weighting, or panic, or any other imaginative happening, we should look at what divers can do to prevent what we know happened. PADI and the other agencies reinforce buddy diving for a reason - having a buddy nearby provides an additional level of safety to the dive. While it is true that many divers choose not to follow buddy rules, those who do have the opportunity to sort out where they stand before they splash. Knowing there is zero help on the dive is far better than assuming someone will be there in your time of need.

 

[MMM]

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A ScubaBoard Staff Message...

thread temporarily closed to more and/or remove off-topic discussion. Marg, SB Senior Moderator

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---------- Post added March 10th, 2015 at 06:54 PM ----------


---------- Post added March 10th, 2015 at 06:55 PM ----------

 

[bowlofpetunias]

This dive was part of a tour with Lost Reef, we had 3 groups diving with guides, my group of 4 being composed of James (who called himself Jim), another diver, a guide, and myself. I had done two reef dives with Lost Reef on the 31st to ensure I was ready for the Vandenburg, as I was only certified this past October for open water diving. I have been in the ocean many times before, snorkling, surfing, swimming, and also being a lifeguard and swim instructor I have more confidence than most who are new to diving. My PADI instructors knew this, and suggested the Vandenburg to me. I also explained this all to my guide, and we agreed I would stick to him through the dive for safety. The guide was a very experienced diver, and had been doing the tours for many years without major incident, and was confident enough in my abilities for the planned dive. We were to descend, group up around 100ft to ensure everyone was comfortable, and make our first penetration from port to starboard and continue touring from there.

As for conditions, visibility was near 80ft, and James was wearing the same type of wetsuit you'll see in my profile picture. Waves were choppy making entry/exit a bit more intense, but I managed well enough. Once we had all entered and grouped up, we descended along a line down to the stern of the wreck (I believe it was buoy 6 for those of you with local knowledge, though I could be mistaking that for another buoy. I'll speak about that later).

Our guide lead and was watching us descend from within arms reach of me, I was following second, the other diver and James were behind me, one of which was following the descent line by visual reference. I'm fairly certain it was James, but at this date I'm not positive and I am starting to forget a few details. At the time I certainly though it was him, and so I could see he was fairly skilled to descend steadily even with the current pushing us a bit. When we reached the deck at around 90ft we moved off the port side of the ship and dropped down another 10 or so feet to where we could see two holes cut into the ship for diver penetration. One was further aft and about 2-5 ft lower, which we grouped up around.

Our guide checked that we were all ok and that we were going to penetrate straight through the ship. The space was only wide enough for one diver to enter at a time, but inside there was a room to our right, some space to our left, and another cut out where you could exit the wreck above in the center of the room. Again our guide led, and just before I followed I noticed James had sunk about 3 feet and was kicking with his hands relaxed in front of him. It looked like he was not establishing neutral buoyancy with his bcd, so I faced him, held up my bcd hose and pointed to it, to which he replied with the ok signal. (On reflection, it could just be that he was cold and wanted to warm up a bit. Being my first dive, I paid absolutely no attention to the cold, and I normally swim in cold water) The other diver was just next to us, so I turned and followed our guide through. About 20-30 seconds after I had finished my penetration the next diver exited, and James never followed.

After about 60-100 seconds, our guide signaled for the other diver and myself to penetrate back through the second spot (the one slightly raised and towards bow) to look around, while he would go back the way we came to ensure we didn't do a chase around. The rooms on that penetration looked too small to navigate with scuba gear, but regardless my other buddy and I saw no sign of James, nor had our guide upon regrouping. We held that spot for another minute or so, and our guide spotted a person almost directly above us on the surface. I would estimate anywhere from 3 to 6 minutes had gone by, but later our guide would tell us he would be hard pressed with his 30 years of experience to make that same ascent that quickly, and he appeared to be in better shape/health than James. (That being said, I have a frustratingly bad memory of names, hence "our other diver", whose name I don't recall. One thing that struck me is I had already started to forget what James's face looked like by the time I had surfaced. While he gave the impression of being a fairly competent diver, he did not look especially fit, nor unhealthy.)
Though I did not recall immediately, I seemed to remember seeing a person on the surface, on their side and horizontal. Either the image didn't make an impression because the figure was not in distress (vertical and thrashing about), or because I was simply imagining it. Additionally, I could have been looking at one of the crew from the ship and have not seen James at all.

Within the next 10-20 seconds after that, our guide made the call to continue our dive (which I know after discussing it with my PADI instructor wasn't the best choice). We continued for about 20 minutes going to shallower sections of the ship, and after we ascended and did our 3 minute safety stop I immediately heard my guide ask the crew member who was helping divers exit the water as to James's whereabouts. All other groups confirmed their divers made no ascents, so it had to be James who surfaced. Upon surfacing, the crew member jumped into the ocean and started swimming out to James, who descended out of the crew's sight before being reached. After all other divers were accounted for, we waited for several minutes looking for signs of bubbles. After 5 or so minutes the crew member who had originally spotted James on the surface geared up to look for signs of James (bubbles, etc). Also our guide got back under with a new tank, and I assume he tested the current while descending. A while after that we started searching on the surface, and finding nothing for about 10 minutes called in the coast guard.

The coast guard did their search over the next few days as you all know turning up nothing, while the sheriffs department could not dive the next few days due to poor visibility. If the search was indeed called off by the 6th than no more than a day or three had been spent actually searching around the wreck.

With my PADI instructor we speculated possibilities, the obvious were medical issues; being in his 50's and the last man through it's possible he had an emergency, panicked and surfaced. Had he become so panicked as to forget to ditch his weight belt and inflate his bcd, we could see that he powered up to the surface, and either from lung expansion, exhaustion, or a medical issue he lost consciousness while still negatively buoyant and ended up as the user Wookie suggested at 160ft aft.

The speculation of intoxication was brought to light by another diver, who was unconfident that it was James he had seen drinking beer, or simply a person of no consequence.
As for the buoyancy of a person, I would say he was so negatively buoyant when I saw him that if he had the equivalent of 17lbs removed from weight he could still have sunk. I don't know the mathematics of the buoyancy provided by ones bcd, but assuming it was really deflated that may affect where he would go.

My memory is by no means perfect, so I may have unintentionally omitted minor details, but those are what I can recount, and I also drew from a video I took the day of the event for certain information, so the majority of what I separate from my own experiences and my thoughts should be fairly accurate.

Bold Added to the points that I used in theorizing. I figured it might be hepful to bring the witness's post forward. there is another which people can go back to.

Your analysis relies on facts not in evidence and seems to be looking to avoid particular outcome. We don't know the victim was stressed about entering the wreck. We do know the victim is missing. And we know the victims' buddy did not stay with the victim. Analyzing the facts, not the speculation, leads back to buddy separation.

I actually don't think we are disagreeing on anything except single cause as compared to contributing factors. You are correct we do not know the reason the victim did not enter the wreck. We do know that he chose not to follow the dive brief at that point. Stress at that stage is speculation on my part. We do know the brief did include the fact that entry was single file and therefor last diver in would not be visible to his buddy at that point.

The witness didn't sound entirely sure who his buddy was, which is evidence that the buddy system was not effective on this dive.

On this point I disagree with you. The parts of the witness's post indicate that he was clear that he was to stay within arm's reach of the guide (for safety). He indicated he did this until the guide indicated he and the other diver should buddy while they went through the other section which made them temporary buddies till they regrouped. That sure sounds like Buddy to me.

Had the victim's' buddy stayed with the victim he may not have been able to save his life, but then the victim would be dead, not missing and presumed dead. On the other hand, the problem may have been something the buddy team could have worked out, but we can never know that because the buddy team split up and the opportunity for a successful intervention was lost.

I mostly agree here. It did not seem clear that the other pair had formally accepted their role as buddies. Had this buddy pairing been more clear perhaps the buddy may have been able to help. Perhaps the missing diver would have abdicated the buddy pairing anyway by not indicated he was not going into the wreck or decided to bold to the surface in a manner that made it unsafe for his buddy to intervene. Even a good buddy can only do so much.

The A&I lesson learned is to stay with your buddy: Before you splash, identify clearly who your buddy is, plan the dive, decide what the buddy team will/won't do on the dive, review hand signals, and perform pre-dive safety checks. It's OK to sort out the dive with your new buddy before you splash. If your insta-buddy is uncomfortable with that, get another buddy.

I agree this should be ONE of the lessons learned from this accident and unfortunately a recurring contributor to dive accidents. I think there are a number of other lessons to learn as well. Plan the dive and dive the plan. Establish and maintain appropriate bouyancy. If you abort a dive ensure your buddy is aware of it and ascend at a controlled rate. Establish positive bouyancy at the surface dropping weights if necessary. If someone in your group aborts a dive ensure they are safely in the hands of surface crew or safely out of the water before deciding to continue the dive. Don't dive beyond your skill set. Lacking a body and equipment we can not rule out or rule in Medical issues or Equipment issues. IMHO if we focus only on one root cause we miss all those other valuable lessons.