Japanese tourist killed by boat prop off of Phuket

[windapp]

This forum is for trying to get to the root cause of each issue, and recommending ways of preventing incidents from happening again. If try to squash every suggestion that implies blame in any way, we will never get to the root cause of anything. The only reason why it looks like I am placing blame is because every suggestion I make results in a defence.

Anyways, here is my take. I have done root cause analysis in manufacturing before. The trick is to keep asking why. Keep in mind I am dealing only with the facts we have seen so far.

What happened: A student was killed on her first dive by runniing into a propeller after having an accidental run-away accent.

Why: Because the Propellers were Running (more on a runaway accent cause in a bit)
Why: Because the boat was position to pick up students, and not anchored.
Why: Because the dive was a drift dive.

Accdental run-away accent:
Why: Because the student was new to diving and made a mistake. The instructor in this case is supposed to prevent the student from doing this but was unable to.
Why: Because the instructor was busy inflating an SMB.
Why: Because the dive was a drift dive and the SMB was necessary before accent for safety.


Both branches lead to the same root cause: The first OW dive for the student was a drift dive.

Now, we can think of ways to prevent this in the future.

One way would be propeller guards as already suggested.

Another would be not to permit drift dives as OW training drives.

A third alternative would be to require another experienced diver to accompany the class, and do any tasks that would otherwise distract the instructor from keeping control of the students if such tasks are required.

 

[Quero]

windapp, maybe it's the way you phrase things, but it sure sounded like you were assigning blame. This last post of yours is more reasonable in tone.

When I say that some of the possible solutions you offer are impractical, that is not making a defense; it is giving you additional information you don't have so that you can better understand the circumstances that hold here. You say you are specialized in root cause analysis, and if this is so, you will know that you cannot make baseless assumptions or assumptions based on unrelated experience, and further, you will know that your assumptions must be founded in a clear understanding of the true circumstances. If the basis for your assumptions is diving someplace other than here, these assumptions are clearly open to error. When we consider the circumstances that exist here, and specifically off the island where the accident happened, the errors you make in your assumptions become clear. For example, saying not to take students on drift dives here is like saying not to train students in New Zealand or Seattle where the water is cold because they might have a runaway ascent and get hurt when wearing a dry suit.

Having said that, you stated:

Keep in mind I am dealing only with the facts we have seen so far.

Where did you get the information that the instructor was busy deploying a surface marker? I have not seen or heard that at all locally. Please state your source.

It's this sort of unfounded assumption that I've tried to provide balancing information for--information that you see as defensiveness. It is not. You simply don't understand the circumstances here and base your critique of the way things are done on guesswork.

By the way, it wasn't Vlad who first suggested prop guards as a preventive response for future accidents. It was me.

 

[windapp]

Anyway, I am not trying to assign blame. I know "root cause" analysis, not specifically accident analysis. They are essentially the same but the politics are very different.

I didn't say vlad suggested the prop guards, Mr X did.

I misread your post about the circumstances of the accent, and read into it that the instructor was deplying an smb at the time. That being said, I still think that instructors doing distracting activities like deploying an SMB is something that should be looked at.

By my earlier post, I meant that there are circumstances where everybody did everything right but "everything right" is wrong. In this case, if everybody did everything right, the procedures need to be revised because the student was not adequately protected by the procedures that have been put in place. It is impossible to predict everything tht could go wrong but when something does go wrong, change is indicated. This is why close-call reporting is so important.

 

[Quero]

I am pleased to read that, windapp. I am certain that the instructor and the captain are both doing a lot of soul searching and are carrying a heavy emotional burden, and it seems unfair to assume that they have been negligent simply because the accident was so horrible. Perhaps it will turn out that they were in fact negligent, but I actually expect that there were a number of contributing factors that tragically aligned that day.

In the spirit of considering factual information, to get an idea of the geography of the dive site where the accident took place, you can find a description and a map here. (Click the thumbnail of the map to enlarge it.) Currents in the Andaman Sea are tidal, so other than when the tide is slack, there is always a current running either southerly or northerly along the island. As you can see from that map as well as this other one, the bay is a small crescent in the island; dives typically start at one corner of the bay, continue across the bay and end at the other corner (or even a bit further along the island beyond the bay), all with the current and not against it. When the current is running, divers would not enter the water from a moored boat and then return to it; instead they would do a drift dive, surface under a marker and wait for a boat pickup. With very inexperienced students, we begin in the shallows in the middle of the bay rather than at one corner of the bay, and then we make our way along the bottom contour to the edge of the reef to do the drift, getting picked up in the usual manner. Keep in mind that in Dive 1 of the Open Water course, there are no required skills to perform--this first dive is meant to be a simple tour in shallow water (maximum depth of 12 meters/40 feet). I have heard that the two divers and their instructor were at a depth of between 9 and 12 meters, or 30 to 40 feet, but I don't have any firm confirmation of that. If that is true, then they were still diving and not ascending.

 

[Hatul]

We are all shocked and saddened here on Phuket at this news. We're still waiting for additional information, though. It's not clear whether the divers were surfacing under a marker. I wouldn't be so quick to tar and feather the Thai boat captain without knowing this detail. I personally find the Thai captains of our big dive boats to be exceptionally gifted at maneuvering the boats for dropoffs, pickups and docking, and while it's possible that this one was negligent, we should give him the benefit of the doubt until more information is available.

Instead of being gifted at picking up divers with their boats, perhaps they should just follow the rule of not using the boat engine when divers are present in the water.

Adam

 

[DandyDon]

Instead of being gifted at picking up divers with their boats, perhaps they should just follow the rule of not using the boat engine when divers are present in the water.

Adam

I don't remember any live boat pickups on my few CA trips, but they're common - even in Puget Sound.

 

[Charlie99]

Instead of being gifted at picking up divers with their boats, perhaps they should just follow the rule of not using the boat engine when divers are present in the water.

Adam

That rule only works if the boat is anchored or moored.

A boat that is about to drift into a shallow reef or a wall will need to move. A diver approaching the boat from below at that time will be in danger.

Boat ops that drop divers on the backside of Molokini, near Maui, always caution divers not to approach the boat underwater. In spite of those warnings, it sometimes happens that while one pair of surfaced divers are being picked up, other divers nearing the completion of their safety stop see the nearby boat and decide to swim over to it for pickup. The problem is when the divers approach the stern of a boat just as it needs to maneuver away from the wall.

From the reports early in this thread, it appears that the boat backed away from a shallow reef just at the same time that a student diver had an uncontrolled ascent.

The only change in procedures that I can see is for instructors/students to be dropped off well away from other divers, so that the boat can stay well away from them until all students are back on the surface.

 

[The Wolf]

I have been in situations where new divers are impossible to control....and even whilst trying to inflate an SMB, have found the group scattered because of strong currents and other factors.

IT HAPPENS. But, when divers take on the responsibility of diving and are "released" after passing the qualifications, part of the responsibility when it comes to safety falls on them. A DM or dive leader can only control so much of a situation.

As much as I hate saying this:

1) we don't know all the facts of the incident
2) the diver must have been aware there were boats up above and to proceed to the surface only when the dm gave the okey to do so

If it was anything else, it was sheer bad luck and a combination of being at the wrong place at the wrong time.

Accidents happen. Sometimes, they are unavoidable. There are all kinds of divers out there.

Some very safe and practical. Others less.

My 20 cents worth on the incident without knowing too much about what happened.

 

[timegan]

very tragic...for sure! Why not spend, less than $500.00 to "cage" the prop. No not on all boats. But dam well on DIVE boats. It just makes sense. The lobster fishin fleet have em. It's easy to do, and works! Added bonus.....not hitting anything that may destroy/harm the prop itself. Oh and people/divers N sea life. Doesn't have to happen...PERIOD!

 

[xjeslesx]

Whenever I am operatoring a vessel I either know the location of my divers and manuever or I don't start the engine. There is no excuse for moving your vessel if you don't know where every diver is, especially if they are scattered around your vessel.
Any details that come out will not excuse the operators lack of attention to divers location.
My sympathy for the family of the late diver.