Fatality at WKP

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Hello, all...

I'm Todd Leonard, one of the Project Coordinators for the WKPP, and one of Jim's friends.

I've been posting info in the accident analysis thread on the Cave Diver's Forum about Jim's accident Saturday, and it seemed to be helpful there in minimizing the speculation that we often see when trying to make sense of the loss of someone from our community. I'm not a frequent contributor here, but I'm hoping that by posting a summary now I might clear up a few of the questions and misconceptions I've read in the thread here so far.

My initial posting was...

I'm very sorry to report to you that our friend and fellow explorer Jim Miller died today during a dive in the WKP.

It's too early for us to report on the dive in great detail, but what I can tell you is that he seized and drowned in the cave after breathing a 70ft deco bottle for an extended period of time on his way into the cave. The bottle was marked and analyzed correctly. The depth was approximately 200ft and the incident occurred soon after the team turned and began their exit. He was brought back to the basin by his buddies following an unsuccessful attempt to revive him at depth, and then to the surface by other team members.

I posted more as I received additional detail, and as I received questions from CDF members who were wondering various things. Rather than trying to assemble and repost all that, however, I think I'll just try to present a chronological summary of the dive:

Jim was diving with two buddies Saturday, each using an RB80 rebreather. They entered at a site in the WKP (Woodville Karst Plain) called Whiskey Still Sink. From Whiskey, the conduit proceeds at a shallow depth to Innisfree Sink, and beyond Innisfree it drops deeper to a max depth around 220ft and continues. Thus, their decompression was to be done on the other side of Innisfree. Their bottom mix was 240 gas. They carried deco gas to be used at 120, 70, and oxygen at 20. Given the offset profile, they did their own deco setup.

They began the dive on their 120 bottles, which are suitable for the shallow cave between Whiskey and Innisfree. Passing Innisfree they dropped deco bottles at their respective depths. The first error occurred at the 70ft stop, where Jim dropped one of his 240 bottles -- he should have dropped his 70ft bottle, and it should not have been carried any further into the cave.

After proceeding down to the 120ft stop, the team stopped for their switch to 240 gas (their bottom gas). At this point the second and most serious error occurred -- Jim switched onto his 70 bottle. Part of our standard procedure and a very critical step in each and every bottle switch is to check the MOD sticker on the side of the bottle, which would have made very clear that he was about to switch to the wrong bottle; we don't know why, but this check was missed. We also want buddies to watch each others' switches carefully enough to confirm the correct bottle is in play, but this secondary check was not performed and the error was not caught. Following the switch the team dropped their 120 bottles, and proceeded into the cave.

They continued into the cave for a little less than an hour (with Jim breathing his 70 bottle), and turned the dive as planned. Not long after the turn, Jim experienced a seizure. His buddies tried unsuccessfully to help him recover from the seizure, and Jim drowned.

After a prolonged exit the team was able to bring Jim back to the basin at Innisfree, and shortly thereafter a pair of our support divers brought him back to the surface.

So, that's the crux of it. There was a significant error, a critical error, plus missed opportunities to catch and correct those errors.

Jim was a very experienced and responsible diver, and known among his friends for his exceptional meticulousness. We're profoundly shocked and saddened to lose him, and he'd be one of the last people we'd ever imagine might die this way. This dive was well within his skill and experience levels, and the site was very familiar to him.

- Todd Leonard
 
Thank you Todd. We all make mistakes; I'm sure everyone is saddened to imagine how many opportunities to stop the incident pit were missed. My condolences to Jim's loved ones and the whole WKPP family.
 
Thank you for this fine honest post. Many will learn from it I'm sure.
 
Thanks for posting here, Todd. Like I stated on CDF, it's refreshing to see such openness and honesty so soon after this incident!



I'm not addressing any particular specific beyond using a specific to illustrate a philosophy of safety procedure development and implementation; that is, how to evolve the best protocols to assure an outcome. On every dive. (A protocol is a set of procedures followed to achieve a specific objective/outcome - like assuring we're breathing a safe gas... where bottle and gas switches and ppO2 monitoring all may apply, depending on the circumstances)
Given that the protocol we develop assures the outcome we desire, (that is, it's foolproof!) I think we can all agree that:
(1) A simple procedure is preferable to a complicated one.
(2) The further upstream you can push a protocol the better. (The earlier you can eliminate a risk the better)
(3) A protocol should be distilled to the fewest procedural steps possible.
That's not to say that good habits should be abandoned. For example, checking the mix on every bottle you breathe during the switch to that bottle is a 'good habit'... It just doesn't need to be part of the switch protocol when all the bottles you have are the same mix. That's vastly different from cylinder pressure checking, simply because the mix in a bottle doesn't change in the water (CCR's an entirely different animal here), but pressure changes for both normal and extra-normal reasons.
but I'm drifting...
In this mishap, what I'm reading is that in the WKPP, because the environment includes dropped pick-up bottles of various mixes, the protocol calls for a formal double check of MOD at every gas switch, whether it's supposed to be a "single gas on board" situation or not. Certainly adherence to that protocol would have prevented this tragedy. As for the bottle drop protocol, and whether any changes are warranted there, I'm still not clear... I know that my own bottle drop protocol was not what it needs to be and will be from now on.
Rick

Okay, well we're on the same page then because that's essentially what I've been saying. Not sure where the misunderstanding came in??
 
Thank you. If only the rest of the diving world were as forthcoming as you have been, it would make a huge difference.
 
This openness and willingness to share information is only what I would expect from the organization that trained me to debrief every dive.

Although it is terribly sad that this accident occurred, I think it is already clear that, because the information was made public, people are changing their procedures as a result of it, to improve safety. We cannot bring Jim back, but we CAN perhaps prevent someone else from dying the way he did, by knowing how it happened.

Thank you, Todd.
 
...Not sure where the misunderstanding came in??
Well, I jumped into the middle of your conversation with a post that wasn't directed at it, but rather at a broader look at what we can take away from this tragedy long-term, so naturally it didn't make a lot of sense without an explanatory lead-in that I should have put in the post in the first place. So 'twas I who pulled the switch and sent the train down the wrong track...
Mea culpa; a thousand gomens :)
Rick
 
Hello, all......>snip<...So, that's the crux of it...>snip<
Thank you Todd.
If it's any consolation at all, the analysis of Jim's mishap uncovered a defect in my own protocols for bottle drops and I have instituted a change that improves safety in the way we will be doing things in the future.
Rick
 
It is my heartfelt conviction that the description of Jim Miller's accident has already saved a life.

Amongst all the readers of this thread there are some who will change their protocols thus preventing their own demise bound to happen in similar circumstances.

Hopefully some consolation for his loved ones.
 
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