Jackson Blue Accident?

[jjoeldm]

Originally posted by Rick Murchison
Whatever did happen at Jackson Blue, it is crystal clear that it is not a "DIR" or WKPP issue. What Jonathan did procedurally probably didn't have anything to do with it either, but without the ME's report we on the sidelines just don't know. The most probable cause - this is my opinion based on grapevine information - is a disease related blockage resulting in a fatal barotrauma. Blamestorming won't do any of us any good, and Jonathan's gone. I'd like to see the ME report for possible "lessons learned" - but without it all is just conjecture.

I think that is probably about right. It's too bad that there is so much pettiness in the cave community and there almost always has been. And ironically it's been largely centered on which hose you breathe. I remember reading an article about a previous Hogarthian who was roundly criticized for promoting that aspect of the methodology now known as DIR.

It was stunning to me, a new cave diver in 1990, how much rancor there was. I had met a lot of these guys and they were almost all great guys. But some of these collections of "great guys" just so happened to hate the other group of "great guys."

The long hose debate, though a serious one and on which I side with the DIR proponents, also reminds me of the tale of Gulliver's Travel's. The Lilliputian's silly war over how you opened an egg. But it's hard to have a dialogue with someone you don't respect and that's the crux, it's not really the egg, it's the egos.

A cave is no place to be even a little off your health.

Well said.

JoeL

 

[The Chairman]

Originally posted by Rick Murchison
Whatever did happen at Jackson Blue, it is crystal clear that it is not a "DIR" or WKPP issue.
(edited for content)
The lesson: A cave is no place to be even a little off your health.
Rick

Well put Rick!

I noticed that on an open water dive once. The deep muscle fatigue that comes with being sick and the latent symptoms that can arise make ANY diving, much less extreme diving dicey. That the diver in question did not have medical clearance to dive indicates to me that the probable cause of death was due to medical complications during the dive. I will change my opinion when we have evidence indicating otherwise. Many divers seem to think they can buck the odds... Its the "That will never happen to me" syndrome. This should be a sobering call to get and heed medical advice before you subject your body to the rigors of diving. No dive agancy, whether it be DIR, WKPP, PADI, NAUI, you name it, should EVER be held remotely responsible for an irresponsible decision made IN SPITE of dire warnings. A procedural discussion is moot when the established procedures are not followed.

 

[Lost Yooper]

Absolutely, Pete.

Mike

 

[Bob]

Rick and the Doc are spot on with their assessment. Diving is no place to be when there is a health issue. As for the ME report, I'm sure the report is finished and has been made avaible to the family. Yes, it would be nice to have access to it for serious divers to learn what went wrong so techniques and procedures could be changed(if needed) to prevent another like occurance. But honestly does anyone think the the ME report will ever be released to the public? It would turn into a sideshow of fingerpointing and I told you so's here on the internet. The battle would rage worldwide. All one has to do is to go back and review this thread if they have any doubts about that. The guy is dead and for that I'm sorry. From the outside looking in, it appears that some are more concerned about the reputation of their agency, than the fact that a person is dead. What a shame that is. Maybe it's time to just let him "Rest in Peace" :tree:Bob

 

[jjoeldm]

Originally posted by Bob
Rick and the Doc are spot on with their assessment. Diving is no place to be when there is a health issue. As for the ME report, I'm sure the report is finished and has been made avaible to the family. Yes, it would be nice to have access to it for serious divers to learn what went wrong and how to prevent it from happening again. But honestly does anyone think the family will allow this to happen? It would turn into a sideshow of fingerpointing and I told you so's here on the internet. The battle would rage worldwide. All one has to do is to go back and review this thread if they have any doubts about that. The guy is dead and for that I'm sorry. From the outside looking in, it appears that some are more concerned about the reputation of their agency, than the fact that a person is dead. What a shame that is. Maybe it's time to just let him "Rest in Peace" :tree:Bob

Bob,

Like you I feel sympathy for the diver's family. Often because of poor planning or just an excess of testosterone or sometimes just bad luck combined with some measure of one of the above, they lose a loved one and usually they could care less for all of the cave politics that go on. As the signs say, "There is nothing in this cave worth dying for."

But I have to disagree with you about the "the guy is dead" and so move on position. People learn by mistakes. It's our best learning tool for the average diver. It's why Sheck Exley wrote BLUEPRINT FOR SURVIVAL using accident reports as an intro to each section. (For those of you who don't know the story) He said that he was driving home one night and was driving very fast. He pulled off at a rest stop somewhere in the South and saw a bulletin board put up by the local Highway Patrol with grisly pictures and descriptions of traffic accidents. It worked. He said he got the message loud and clear and drove the speed limit the rest of the way home. He then took the same approach with BLUEPRINT.

Accident reports are crucial to scaring the crap out of some people who are engaged in stupid activities. For some they are a indicator of what NOT to do. For others they are sobering reminder of what happens to a careless or cavalier diver.

The death itself is the tragedy. When John Kennedy died do you think the NTSB should have kept the report quiet? Flight 800? That Lear Jet with the golfers? The plane full of skydivers? Should they just hand reports on private pilots to their wives and ignore the rest of us, even when there is a clear lesson about maintenance or carelessness or stupidity? Did we learn anything as pilots/manufacturers/public that was at all useful? I'm not a pilot (would love to do it someday), how exactly DO they approach it?

As badly as I feel for these wives and loved ones, as you say, "the guy is dead", so my attitude is, let's take care of the living, make the reports completely honest and available for divers as soon as is practical. Those who love the diver will see to it that he is remembered well and measured for the whole of his life, not just for the last hour of it.

Every time there's an accident, I wait for a final report, because it's critical for me as a cave/tech diver to see if there's something in there that I do that I may think is safe today, but that lead either directly or by a downward spiral of events, to this diver's death. As for the flame wars, they will always be with us and I feel that the LACK of an honest report contributes to the firestorm because without the facts, all the would-be SCUBA-Rush-Limbaughs out there are free to say whatever with nothing to rebut it.

The Truth, delivered in a complete and timely manner is the best approach.

JoeL

 

[jimholcomb]

....I have been very disappointed in my attempts to get the IUCRR to issue final reports quickly and to EVERYONE. As it stands now, the "eyes only" preliminary incident report is issued promptly to IUCRR members but the final accident analysis is only reported at the end of the year in the NSS-CDS and NACD's prospective journals. Prior to Henry's passing, I had BEGGED him to speed up the accident analysis process and disperse it immediately to every one interested - not just the cavediving community. Accident analysis and the following discussion probably saves a lot of lives - so why wait till the end of the year?

 

[jjoeldm]

Originally posted by jimholcomb
....I have been very disappointed in my attempts to get the IUCRR to issue final reports quickly and to EVERYONE. As it stands now, the "eyes only" preliminary incident report is issued promptly to IUCRR members but the final accident analysis is only reported at the end of the year in the NSS-CDS and NACD's prospective journals. Prior to Henry's passing, I had BEGGED him to speed up the accident analysis process and disperse it immediately to every one interested - not just the cavediving community. Accident analysis and the following discussion probably saves a lot of lives - so why wait till the end of the year?

Thanks for the note Jim.

One thing that is frustrating is that , as you say, these "raw" reports are sent to the members of the IUCRR. This inner circle of CDS and NACD leaders and members _may_ use such reports to quietly change something in training, but I doubt that this happens very often. Why is it that these guys, by dint of being part of this "clique," get special access to information that could be information that could save lives and we don't?

I believe that Henry was a good man. I considered him a friend and I mourn his passing. In his long and active history he accomplished a lot for diver safety, but in the end I feel that a partisan board steered IUCRR policies to remain proprietary and secretive, letting only stats and the occassional report to come dribbling out. Valuable though those are, one person and a computer could have the entire database collated and released in a few weeks and I am DEAD SURE that such a document/web page/whatever could save lives.

If one withold information that could save even one life, doesn't that make one somewhat liable and responsible (ethically, if not legally)?

Cave diving should be an open system that has as its primary purpose and goal the promotion of safe cave diving techniques and NOT to encourage more and more new cave divers, many of whom are either not ready or who will never dive with sufficient frequency to make it safe. The reality is far short of this, IMHO and the infighting between groups just makes those who would keep it a clique better able to maintain the status quo.

Instead, based on much of what I hear and see via the grapevine the old agencies at times seem to be there primarily for their own protection and the welfare and promotion of the professional instructors. To some extent they secondarily focus on the welfare and safety of their students. That is my opinion. Yes, there are good, honest, caring, safe and intelligent instructors within the system and I have some reasons to hope and believe that there are people involved who are working hard to make it better, but the so-called powers-that-be are slow to move. GUE is a bright light on the horizon as well.

Having a searchable database of ALL accident reports going back to the beginning would go a long way towards giving these new, often undertrained
and inexperienced cave divers something to wake them up to the reality of what they are engaged in.

JoeL

 

[jimholcomb]

In defense of the IUCRR on a couple points, the hesistation on their point to release raw data to the public stems from legal issues that may (and have in the past) arise. And I believe the information is shared with GUE and IANTD along with the ones previously mentioned. My beef is the final report. As an IUCRR diver - I see the raw report almost immediately BUT I don't even see the final report until I read it in the journals. I don't find that acceptable in that that information could save lives. It also leads to a bunch of speculation and hearsay that clouds the issue by the time a cause is determined. I do believe as time passes the IUCRR reporting will become much more open and timely.

 

[Rick Murchison]

Originally posted by jimholcomb
In defense of the IUCRR on a couple points, the hesistation on their point to release raw data to the public stems from legal issues that may (and have in the past) arise.

There is nothing more dangerous to the free exchange of the truth in this country than a trial lawyer. Who's going to tell the truth when it could mean financial ruin for them and their family down to their children's children's children? The same goes for an agency's liability. What is needed is a no-liability forum where actions and procedures, practices and equipment and every detail of a mishap can be discussed openly and truthfully without the fear of any action in the legal system, where the people involved in gathering the facts, all the information they gather, all the discussions they have and all the conclusions and recommendations they reach are specifically proscribed from release in any legal proceding. The "legal" investigation will be done by different people under the regular rules where witnesses know that anything they say can and will be used against them - but the "safety" investigation must be a place where the witnesses know that anything they say *cannot and will not* be used against them by anybody - not by the legal system, not by their certifying agency, not by OSHA or EPA or NOAA or any other government or civilian entity. They must know that what they say *cannot and will not* ever see the light of day with their name on it, and *cannot and will not* ever be allowed in a court of law under any circumstances. A board of this nature would of necessity meet in confidentiality and its eventual report and recommendations scrubbed of names, dates and places. The publication of the results with referrence to any specific incident must be criminal; its use would be restricted specifically to the improvement of diving safety.
Provide those protections and there's a pretty good chance we'll have access to the truth and be able to learn and grow. Otherwise we'll have to stay with our current system of rumor, guesstimates, inuendo, finger pointing and whispered suspicions.
This is not just "pie in the sky." Such a system could be modelled after procedures already in effect at the Naval Safety Center. As a trained Naval Aviation Safety Officer I'd be glad to help get such a Diving Safety Organization off the ground.
Rick

 

[jjoeldm]

Originally posted by Rick Murchison

There is nothing more dangerous to the free exchange of the truth in this country than a trial lawyer. Who's going to tell the truth when it could mean financial ruin for them and their family down to their children's children's children? The same goes for an agency's liability. What is needed is a no-liability forum where actions and procedures, practices and equipment and every detail of a mishap can be discussed openly and truthfully without the fear of any action in the legal system, where the people involved in gathering the facts, all the information they gather, all the discussions they have and all the conclusions and recommendations they reach are specifically proscribed from release in any legal proceding. The "legal" investigation will be done by different people under the regular rules where witnesses know that anything they say can and will be used against them - but the "safety" investigation must be a place where the witnesses know that anything they say *cannot and will not* be used against them by anybody - not by the legal system, not by their certifying agency, not by OSHA or EPA or NOAA or any other government or civilian entity. They must know that what they say *cannot and will not* ever see the light of day with their name on it, and *cannot and will not* ever be allowed in a court of law under any circumstances. A board of this nature would of necessity meet in confidentiality and its eventual report and recommendations scrubbed of names, dates and places. The publication of the results with referrence to any specific incident must be criminal; its use would be restricted specifically to the improvement of diving safety.
Provide those protections and there's a pretty good chance we'll have access to the truth and be able to learn and grow. Otherwise we'll have to stay with our current system of rumor, guesstimates, inuendo, finger pointing and whispered suspicions.
This is not just "pie in the sky." Such a system could be modelled after procedures already in effect at the Naval Safety Center. As a trained Naval Aviation Safety Officer I'd be glad to help get such a Diving Safety Organization off the ground.
Rick

Rich,

I hope you are able to make your suggestions heard. I made a suggestion a few years ago, that it seemed to me that the NACD and the CDS were redundant (I suppose in keeping with good cave diving skills ) in so much as they each had not many more than 1,000 members each and probably not even that these days and many of those belonged to both organizations. I had the temerity to point out that since they meet within a few miles of each other, have the same mandates, dive the same caves in much the same way and have almost identical requirements for certification & etc that maybe they should merge for the good of their members. The only real difference that I can see is that the NACD offers their Wakulla Award certificate for 100 safe cave dives to any cave diver regardless of affiliation, but the CDS offers their Abe Davis award, for the same thing, only to their members.

They both collect dues, they both certify divers, they both have a conservation ethic, they both promote diver safety and they both support exploration and mapping of cave systems. In both cases the majority of their members come from the SE, principally Florida and they both have an international membership. There are so many inefficiencies and wasted money, IMHO. This will NEVER happen for obvious reasons

These protect their turf jealously. I'd love to see you make your suggestion to both organizations, but be prepared to be ignored and/or disappointed. I love the suggestion, BTW.

Here is who you should contact:

The NACD Board:

http://www.safecavediving.com/bod.html

And the CDS Board:

http://www.cavediver.org/bod.htm

Good Luck!

JoeL