Fatality at WKP

[DandyDon]

I had no idea what WKP meant here, but found this: Woodville Karst Plain - Wikipedia, the free encyclopedia in case there are others who don't know about the extensive cave system by name.

 

[A&I Mod]

The purpose of this forum is the promotion of safe diving through the examination and discussion of accidents and incidents; to find lessons we can apply to our own diving.
Accidents, and incidents that could easily have become accidents, can often be used to illustrate actions that lead to injury or death, and their discussion is essential to building lessons learned from which improved safety can flow. To foster the free exchange of information valuable to this process, the "manners" in this forum are much more tightly controlled than elsewhere on the board. In addition to the TOS:

(1) You may not release any names here, until after the names have appeared in the public domain (articles, news reports, sheriff's report etc.) The releasing report must be cited. Until such public release, the only name you may use in this forum is your own.
(2) Off topic posts will be removed and off topic comments will be edited.
(3) No flaming, name calling or otherwise attacking other posters. You may attack ideas; you may not attack people.
(4) No trolling; no blamestorming. Mishap analysis does not lay blame, it finds causes.
(5) No "condolences to the family" here. Please use our Passings Forum for these kinds of messages.
(6) If you are presenting information from a source other than your own eyes and ears, cite the source.
(7) If your post is your hypothesis, theory, or a "possible scenario," identify it as such.
(8) If your post is about legal action that concerns a mishap, use the Scuba Related Court Cases forum.
Thanks in advance,
Rick

I've moved the first five posts in this thread to Passings...
Please post your condolences there.
Thanks.

 

[Rick Murchison]

... I assume that the intention was to come back from a relatively deep / long dive with a first deco bottle from 120ft, then to switch to the 70ft bottle at 70ft on the way up...

Don't think so. As the 70' bottle was used from 120' on the way in, I would think that the bottle left at 70' - and what he thought he was breathing - was a stage of bottom gas.
---
This mishap, and thinking about how it might have happened, has got me taking a hard and critical look at my own procedures. If I'm right, the intent was to have only bottom gas aboard when the switch to the stage was made, and so not only would buddy verification of the mix not be needed, it would just be a waste of time. The fatal error was in dropping the wrong bottle; the failure was in the bottle drop protocol.
And there is a weakness in my own protocol there... we have never set a hard and fast rule that a bottle drop be treated with the same double check and positive confirmation of MOD that a deco or travel gas switch requires. After all, it isn't a gas switch, is it? But this mishap proves that it is!
Henceforth and forever more, I will treat a bottle drop with the same respect as a deco gas switch, requiring the same buddy confirmation of MOD, and that the gasses we're carrying deeper are the gasses we intend to carry deeper.
Rick

 

[Kevin Carlisle]

A simple mistake, that's all this is and the results are disastrous. We have lost way too many experienced cave divers this year. May the rest of us not let the simpliest routine go overlooked. Slow down and think please!!

 

[Jax]

Don't think so. As the 70' bottle was used from 120' on the way in, I would think that the bottle left at 70' - and what he thought he was breathing - was a stage of bottom gas.
---
This mishap, and thinking about how it might have happened, has got me taking a hard and critical look at my own procedures. If I'm right, the intent was to have only bottom gas aboard when the switch to the stage was made, and so not only would buddy verification of the mix not be needed, it would just be a waste of time. The fatal error was in dropping the wrong bottle; the failure was in the bottle drop protocol.
And there is a weakness in my own protocol there... we have never set a hard and fast rule that a bottle drop be treated with the same double check and positive confirmation of MOD that a deco gas switch requires. After all, it isn't a gas switch, is it? But this mishap proves that it is!
Henceforth and forever more, I will treat a bottle drop with the same respect as a deco gas switch, requiring the same buddy confirmation of MOD, and that the gasses we're carrying deeper are the gasses we intend to carry deeper.
Rick

Pardon this newb . . . My AN/DP instructor drilled it in that ANY time you change gas (okay, not sidemount), you (the diver) does a reg hose trace to bottle, and Name/mod check, and depth check. Then your buddy does the same, and gives you the okay. Are you guys saying this isn't done with a stage?

 

[Kevin Carlisle]

Pardon this newb . . . My AN/DP instructor drilled it in that ANY time you change gas (okay, not sidemount), you (the diver) does a reg hose trace to bottle, and Name/mod check, and depth check. Then your buddy does the same, and gives you the okay. Are you guys saying this isn't done with a stage?

Its done more thoroughly with the wkpp members than anyone else. We might not agree with every way of thinking these guys do but they do have an impecable safety record. Its really shocking this happened to one of them.

 

[SuPrBuGmAn]

For those unfamiliar with this section of Leon Sinks, I'd guess they went downstream from Whiskey Still to Innisfree and dropped deep.

 

[Rick Murchison]

Pardon this newb . . . My AN/DP instructor drilled it in that ANY time you change gas (okay, not sidemount), you (the diver) does a reg hose trace to bottle, and Name/mod check, and depth check. Then your buddy does the same, and gives you the okay. Are you guys saying this isn't done with a stage?

Okay, first let's consider a single mix scenario. If all the bottles you're carrying have the same mix in them, then there's no need to do an MOD check during a switch, 'cause you're just switching bottles, not gasses.
Now let's consider a simpler plan than was likely the case here, but will illustrate the point well. You enter the water at Jackson Blue (max depth about 95' for this dive) with EAN32 on your back. You have a deco bottle of EAN50 and two stages of EAN32 slung. You're breathing your first stage to start the dive, and drop your deco bottle at 70'. Now you have the stage (EAN32) you're breathing, another stage of EAN32, and the EAN32 back gas. So now you're back in the one gas scenario... There's no need to check gasses when you reach switch pressure on the first stage... you just drop it and switch to your second stage, 'cause all the gas you have is the same gas; there's no chance of making a mistake w/r/t MOD, if you made a proper drop at 70'.
So, if all the gas you have is the same gas, then no, there's no need to do any kind of double checking. My point in my previous post is that this mishap tells me that the deco bottle drop must be treated with the same checks as a gas switch when you're carrying different gasses at the drop, because if you screw it up then the "it's all the same gas" procedure will be invalid later in the dive.
Rick

 

[Ayisha]

... we have never set a hard and fast rule that a bottle drop be treated with the same double check and positive confirmation of MOD that a deco gas switch requires. After all, it isn't a gas switch, is it? But this mishap proves that it is!
Henceforth and forever more, I will treat a bottle drop with the same respect as a deco gas switch, requiring the same buddy confirmation of MOD, and that the gasses we're carrying deeper are the gasses we intend to carry deeper.
Rick

This should be a sticky. If there's ever a clear lesson to be learned from an unfortunate accident, this seems to be an important one.

 

[Dive-aholic]

Not only do bottle drops need to be treated with the same checks as gas switches, but if you are picking up a bottle someone else dropped, the markings on that bottle need to be checked. Just speculation, but there may have been a little too much trust in the procedures and not enough verification.