Horizon Dive Adventures Complaint Filed in Federal Court

[mderrick]

The whole situation is like that. I'd love to have one person to point my finger at, but I see a perfect storm of incompetence or lack of hubris that all came together in one place and a man died because of it. Is he to blame? Partially. Is the instructor to blame? Partially. Is the boat to blame? It all came together and any little thing going right could have broken the chain. Nothing went right, and it was set up for nothing to go right.

There is actually a term to describe this circumstance; Swiss Cheese Accident Model

The model is often applied to aviation and healthcare accidents. In my experience examining dive accidents, typically the chain of errors is long. The error chain can sometimes be so very long as to defy all logic and reason. The chain of errors is also "fragile" in that like a row of falling dominoes it's easy to stop the process by simply stopping a single domino from falling. Thus by preventing a single error in the chain of errors leading to catastrophe the accident is prevented. A common (but perhaps flawed) position advocated is that ultimately the diver must take responsibility for their own safety because they are only person in the chain that has visibility of the entire process end-to-end.

In litigation it often becomes about who was responsible for stopping the error chain, when it could have been stopped anywhere in the process. Keep in mind that litigation is not normally about determining accident causation, it is about determining and apportioning legal liability.

 

[Johnoly]

... In my experience examining dive accidents, typically the chain of errors is long. The error chain can sometimes be so very long as to defy all logic and reason. The chain of errors is also "fragile" in that like a row of falling dominoes it's easy to stop the process by simply stopping a single domino from falling. Thus by preventing a single error in the chain of errors leading to catastrophe the accident is prevented.....

One of the best and most informed posts in a long time. So many family and friends want to point a single finger at moment in time because it's easy to do. But the reality is the accident started WAY BEFORE the final breath.

 

[Bob DBF]

Interesting point, I believe it has been stated earlier in this thread that the boat was manouvering under power to position themselves to pick up the divers, it is possible that the safety diver was the closest diver or in the way and it made sense at the time to pick him up first.

From my reading the safety diver was in distress, the other diver gave the OK sign. Considering the amount of reading over time, I could have misread or remembered a misquote. I would always pick up a distressed diver first.


Bob

 

[Wookie]

When I did this for a living, I always picked up the diver closest to the boat first. But made damn sure someone kept their eyes on the other divers. I learned this through experience. I gained experience through close calls.

 

[rjack321]

When I did this for a living, I always picked up the diver closest to the boat first. But made damn sure someone kept their eyes on the other divers. I learned this through experience. I gained experience through close calls.

As far as I can tell Rob was in sight while the boat did the "Williamson turn" (sic) to go get him. So perhaps the more salient issue is why the deckhand didn't jump in, throw a longer tag line, or even throw a life ring to him. It's easy to Monday morning quarterback that decision, perhaps its just a basic lifesaving reminder.

 

[uwxplorer]

As far as I can tell Rob was in sight while the boat did the "Williamson turn" (sic) to go get him. So perhaps the more salient issue is why the deckhand didn't jump in, throw a longer tag line, or even throw a life ring to him. It's easy to Monday morning quarterback that decision, perhaps its just a basic lifesaving reminder.

Maybe you could spend the time reading the witness statements?
The deckhand was busy with helping providing assistance to Sotis.
Maybe you are going to ask why was he providing assistance o one of his customers?

 

[rjack321]

Maybe you could spend the time reading the witness statements?
The deckhand was busy with helping providing assistance to Sotis.
Maybe you are going to ask why was he providing assistance o one of his customers?

I understand there was a lot of confusion on the deck at the time because Sotis was unconscious and Rob was still in the water. But he was "in sight" at some level or another since the captain was maneuvering the boat to get him.
Sadly people drown in front or next to lifeguards all the time. Divers on the surface are not all that different in that regard.
I would say it seems self evident that nobody on the boat recognized he was in distress or drowning even though he was in sight and close at hand. This is probably why
Drowning Doesn't Look Like Drowning

 

[uwxplorer]

I understand there was a lot of confusion on the deck at the time because Sotis was unconscious and Rob was still in the water. But he was "in sight" at some level or another since the captain was maneuvering the boat to get him.
Sadly people drown in front or next to lifeguards all the time. Divers on the surface are not all that different in that regard.
I would say it seems self evident that nobody on the boat recognized he was in distress or drowning even though he was in sight and close at hand. This is probably why
Drowning Doesn't Look Like Drowning

Even if someone had seen him pass out and start sinking, it 's not clear that he could have been brought back. A fully equipped diver ready to jump and dive for him would have been needed. And even then a lot of skill and luck would probably have been required (no gas to inflate the BC, no drysuit).
The deck was stacked against them the moment they jumped for that 3rd dive.

 

[Wookie]

Even if someone had seen him pass out and start sinking, it 's not clear that he could have been brought back. A fully equipped diver ready to jump and dive for him would have been needed. And even then a lot of skill and luck would probably have been required (no gas to inflate the BC, no drysuit).
The deck was stacked against them the moment they jumped for that 3rd dive.

My wife rescued a rebreather once. I say rescued a rebreather because she got to the diver (flooded counterlung) at about 10 feet, got him untangled from his unit, and brought the unit to the surface, where she held on to the surface float on the tag line while I boated the diver, who was weak but conscious. So it can be done, but I had a boat staff of 8. Different story.

 

[Couv]

So it can be done, but I had a boat staff of 8. Different story.

....and if I'm not jumping to conclusions, just the one diver in distress getting all the attention at the time.

Did anyone on board know Stewart was also having difficulties?