Lessons learned- embarrassing but true

[Diver0001]

It never degenerated into a quadruple solo dive but at times it was me and Mr. Vertigo ahead of the other two divers by a margin that was too great to bridge with lights.

So it was two buddy teams at times not one big team. This is of course not how it should go and not how the dive was briefed. The agreement was that the instructor candidate (who I've been calling Mr. Vertigo to keep it clear... this is not intended as an insult) would lead the dive on the bottom and once stops started I would take over navigation in mid-water. We thought I would have the best chance of getting that right since I've done it many times before. During the swim out the diver with the drysuit issues fell behind. I noticed this and asked him to stop and wait a few times but you're right to describe it as "spring action". That's how it felt to me as well. I primarily train OW divers so any separation more than a few metres activates my alarm bells and I was having that on the swim out.

I think the issue there is that Mr. Vertigo was distracted by being dizzy and wasn't mentally "right here, right now". On the other hand, this diver is learning communication (which is why he's diving with us) and during the dive I missed seeing that he was having an issue because I assumed that it was just the nature of this particular beast to some extent.

At this point in the dive it had already become quite a-typical and we should have called it. I believe (and he agrees) that the guy with the drysuit issues should have called it after about 5 minutes when he realized it was going to be a fight and Mr. Vertigo shouldn't have swum any further once he had initially become dizzy.

I had already called one dive previously due to not feeling focused enough (it had been very busy at my work and I was tired and distracted) so it shouldn't have made them feel ashamed to "let the team down" or whatever. This is where I think egos and/or complacency -- thinking that it would all be ok -- played a role.

I didn't call this dive either. Maybe I should have. I was getting increasingly busy tending to my buddies but by the time I was *really* unhappy with how things were unfolding we couldn't just abort the dive. So somehow... we had to get this incident chain unbunched and to get back in control. I was really unhappy with Mr. Vertigo at the time for putting the team in a position where 2 of the divers were going to be completely off the map in terms of their deco status. I was equally unhappy with ascending above him even though visibility was very good and we were able to follow him through part of the swim back. The guy with the drysuit issues *seemed* like the biggest problem during the latter part of the dive because he physically needed to be helped by two other divers in a situation where you should NEVER expect this... and all the while there was a little voice in the back of my head saying, "we're going to have an accident", which became very distracting to me once I couldn't see the diver who swam back along the bottom anymore.

One more thing. In our local area many divers are accustomed to diving solo. It was briefed before the dive that if we had a buddy separation that the diver who was alone was going to have to finish the dive solo. I think if I were the instructor (going back a couple of posts) I would have chosen option "c" since the two students communicated well and had proven on previous dives that they could do stops and stick to the plan. I think the instructor chose option "d" because he was viewing it as a buddy separation and we had a protocol for that. My conscience says that this was the wrong choice because at that point in the dive Mr. Vertigo was the only buddy who was expressing that he had an issue.

The more I write about this, the clearer it gets to me. I think I'm going to sell my diving gear and take up bowling... LOL

R..

 

[Subcooled]

Some of it for sure

This thread has been an interesting read. Thanks to you guys.

 

[TSandM]

Rob, this incident is kind of like running a resuscitation in the ED -- you have a bunch of things happen quickly, you do the best you can at the moment, and then you sit and replay the sequence over and over in your head, trying to figure out how it could have gone better. The most important thing is to back up and realize that everybody got home in good shape, which means what was done worked. That doesn't mean it couldn't have been done better, and it's that refinement that comes out of reviewing and analyzing the event.

Danny Riordan once interrupted a blamestorm in the Dos Pisos parking lot by remarking that we could spend our time trying to figure out whose fault it was, or we could just try to figure out what we could do to prevent a similar event. In this case, it sounds as though, as in most incidents, there were things that should have been fixed before getting in the water, and once IN the water, the biggest issue was communication. That was the overriding theme of my recent re-do of Cave 1 with JP; many things can be dealt with if the communication is good, and trivial things can become major if it is not. Underwater communication is so difficult sometimes that it is really important to have a set of understood signals, and try to cope with issues before anything more complicated is required.

 

[boulderjohn]

So, it was your INSTRUCTOR who decided to let a diver with a poorly understood problem go back to shore BY HIMSELF??? I just lost a great deal of respect for the man.

I do some accident investigation and reporting on behalf of the NSS. Not long ago I was asked to do an investigation of an accident that happened a few years ago. In it, an instructor was working with a student, and a former student joined the team for the dive, not as a student. The dive had just begun when the former student indicated trouble equalizing and turned to return to the surface. They were at about 40 feet deep at that point, IIRC. The instructor saw her part way back and then returned to complete the dive with his student.

After she was found dead, the lawsuit was quite ugly. It was settled, so I cannot quote an adjudicated outcome, but the contention from the plaintiff (and the expert witness hired by that side) was that if anyone thumbs a dive, it is the obligation of everyone who is part of the dive to accompany that person to complete safety. The argument for the defense was that the victim was not a student on that dive and thus free to act individually on her return. If she had been a student, the instructor's liability would have been clear.

 

[danvolker]

I do some accident investigation and reporting on behalf of the NSS. Not long ago I was asked to do an investigation of an accident that happened a few years ago. In it, an instructor was working with a student, and a former student joined the team for the dive, not as a student. The dive had just begun when the former student indicated trouble equalizing and turned to return to the surface. They were at about 40 feet deep at that point, IIRC. The instructor saw her part way back and then returned to complete the dive with his student.

After she was found dead, the lawsuit was quite ugly. It was settled, so I cannot quote an adjudicated outcome, but the contention from the plaintiff (and the expert witness hired by that side) was that if anyone thumbs a dive, it is the obligation of everyone who is part of the dive to accompany that person to complete safety. The argument for the defense was that the victim was not a student on that dive and thus free to act individually on her return. If she had been a student, the instructor's liability would have been clear.

John,
Are you saying not just the buddy team where one must accompany the other..not just instructor student...but....an entire group that could be composed of many divers that do not plan on diving with the one thumbing the dive, anyway?

I can see the instructor or other members of a buddy team having liability, particularly if buddy understanding exists about what being buddies entails....

Practically speaking though.....the way most boats do drift dives in S fl ( statistically relevant as a place with lots of divers, students, and tourist divers) , if a member of a buddy team, that is part of a lose group of 6 or 8 that was dropped with a float line, if this person runs low on air and wants to surface....his buddy may, or may not ascend with them...most will just go straight up to the surface or stop, and stay with the float, the buddy with lots of air left may finish the dive with the others below--or may ascend with the low on air buddy, if that is the type of buddy team they are......tens of thousands of divers doing this each year.

My point is that what is customary, apparently has no relationship to what is suggested in court, as normative behavior.

 

[Redshift]

I also fee that the communication issues turned the dive into a solo dive for all in the sense that you may not have been alone (and that may even have saved the dizzy diver), but being a buddy is not just being physically there. Two of the divers had problems and did not communicate them and did not let others help and control the situation and decided to pursue their own ideas, when they should have let the team guide the end of the dive. And that's also where I think the instructor should have tried to be more firm.
Besides, when you were 2 + 2, it was a situation where the instructor could not oversee all the students.
I have been dizzy during a dive. I stopped and called my buddy, said I wasn't feeling fine and he remained close to me while I was figuring out what was happening, I didn't just bugger off.

 

[boulderjohn]

John,
Are you saying not just the buddy team where one must accompany the other..not just instructor student...but....an entire group that could be composed of many divers that do not plan on diving with the one thumbing the dive, anyway?

I was just repeating the plaintiff's argument in the case. In support, the expert witness for the plaintiff cited language from the NACD that said something to that effect.

IMO, someone does need to accompany a diver who turns a dive to safety, especially if that diver indicates any sort of health-related issue that led to that decision. I don't think it needs to be the entire team, though.

 

[fsardone]

Hello Diver0001,

First of all, thank you for sharing.
Let me drop my 2c and share my lesson learned in a vertigo incident.
A couple of years ago, when I had just gained my normoxic trimix c-card, I went with my usual buddy for a nice 60 meters 20 minutes dive on 18/45 with EAN50 and oxy as deco gases.

Well, during descent my buddy had slow than usual descend rate, when we reached the wreck on the high portion of it (52 meters) he was slow and leaning. I asked him if he was ok and he was not focused so I thumbed the dive, brought the team up to degassing depth (39 meters if I remember correctly) and stopped. I investigated with wet note about the issue and found out he was experiencing vertigo.

At that point assessed the situation, used ratio deco to identify my best deco plan, wrote it down and shared with the team and, backed up by my mixed gas computer, we elected to decompress on EAN50 alone (we had shortened and shallowed the dive) also to reduce the risk in maintaining precise depth on pure oxy.

My points are:
-if anything is wrong thumb the dive no matter what
-if anybody thumbs it everybody does it (team mutual support)
-better safe than sorry (thumb early and scrap the dive goal-safety is paramount)
-being on fast gas (He rich trimix) makes very risky going up and down
-have contingency plans (did you brief abort plan and team separation?)
-be authonomous in your dive planning (and emergency handling)
-more than 2 students (in any class) is too much to handle for a single instructor without help

I am also a pilot (and instructor) and I find many similarities between flying and (tech) diving. In an emergency the three steps are: maintain aircraft control, analyse the situation, take proper action
in Diving is Breathe, and then no change! Lack of effective communication is an obstacle to analyse the situation. Break down of communication in a team for me is a good enough reason to thumb the dive. And the team thumbs it.

After my dive with the vertigo buddy, I did many more and had a few issues (lost deco gas, separated from buddy, got stuck in a wreck in zero vis and lost buddy-a really scary one, the usual silt out/zero vis in cave) and reached my hypoxic trimix cert and cave cert. The three steps for emergency handling served me well, I learned to be self sufficient/self reliant (I am also solo cert). Also from my flying experience I have learned that I need a thourogh briefing if I do not know well my team mates (formation flying or crew mates) and I can "ass u me" more on my usual team without making an ass of you and me ... which is applicable to diving as well: with new buddies talk more when you can (before the dive and after it! Debriefing is more important for the learning process to me than the briefing itself, which is important for a safe dive).

The more contingencies you plan in advance the smoother the execution will be.
A great pilot is the one that uses his superior planning abilities to avoid situations in which he would have to use his exceptional piloting skills. (The reader is left with the task of translating this to a diving situation )

To sum it up: I believe this dive was affected by poor planning and a very bad briefing which failed to highlight contingency procedures which lead to severe lack of communications and ultimately to team breakdown and unpredictable behaviours.

Hope to have contributed some insight and food for thought rather than appear an armchair referee. We all learn from our mistakes, sometime paying high price for this. Having the chance to learn from other's mistakes is a great privilege that comes at no cost. Thanks again to the OP for sharing it with us.

Fabio

 

[Diver0001]

Just want to thank everyone for your feedback on this dive.

As a followup, I cancelled the next dive and explained to the instructor what I would like to do to turn this around. I believe it's part of the training to "own" this problem and decide how to handle it. The instructor steered this well by setting boundaries for the next dive and asking everyone to offer input about how to approach it. My initial reaction was to propose a change to the planning so we could conduct the entire dive on the bottom but I ended up proposing to cancel the dive entirely and take a step back. We need to make the team central and iron out the communication problems. I'll spare you all the ensuing discussion but basically the conclusion boils down to a few things:

1- no dives right now with 50m and the complications of diving tables at the lake we're using until we take a step back and work on communication. The team isn't clicking. We're all working too much on prior experience and individual habits and assumptions. I want this issue on the table and I want the next dives we make together to be a LOT tighter. Part of the reason I want to put in this effort is that I have a good "social" click with one of the divers (the drysuit guy) and I want to keep diving with him after the course is over..... but not like it's going now.

2- I invited the diver with the drysuit issue (the future buddy) to make a series (4-6) dives with me and my regular buddies using air and nitrox in 30-35 metres to work on communication, getting aligned and drilling procedures in mid-water. We already communicate fairly well but the added benefit of shallower water will give us more time under less pressure to work on breaking each other in. In addition, my regular buddies, as I said before, work together like a machine. I would like to have him click into this machine so we can bring that back into the context of the course.

3- The other diver (mr. Vertigo -- which once again was said for clarity and not to insult anyone) is someone who I don't expect to have a long term connection with as a dive buddy. However, regardless of that this team needs to work more on slowing down, watching, looking and communicating and as long as he's able to do this and we can make our dives without risking another ****-up then I'm happy to have him on the team. We will have to decide how to approach this before the next dive.

4- In terms of backup plans I don't want to make any more dives on tables without a computer for back up. We don't have ratio-deco in the pocket so I want another method to create flexibility.

5- I'm going to make the next trimix dive 1:1 with the instructor. We've dived together a fair bit over the years and I know for sure that I can dive with him without a lot of "noise" in communication. I want to do this so I can focus on any procedural points that I need to tighten up without the added complication of having to deal with team dynamics. After that I'll add myself back to the team again.

R..

 

[TSandM]

That sounds so much like you . . . and sounds like a great way to address the issues.

Can I be a bit smug, and say that, in my niche of the diving world, these issues nowadays get ironed out early, way before somebody is permitted to step up to technical training? . (You know I'm teasing you.)