Lessons to be learned-Death in Palau

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I have one "rule #1" for diving with someone - anyone can call a dive at any time and for any reason or no reason whatsoever. No recriminations if either person does.

If you're not comfortable, you don't go. If you BECOME uncomfortable, then you stop. If you or your dive buddy will not agree to this, find another person to dive with or get a suntan, because the "I gotta do this" mentality can get you killed.
 
I think Detroit Diver has accomplished what he set out to do with this thread. There's been allot of interest and disscusion with a few questions brought up here and in a couple new threads started as a result of this one.

It sure has opened my eyes a little wider.

Well done DD and bravo to your friend the nurse. She did an admirable job.
 
Aquabella once bubbled...
I think Detroit Diver has accomplished what he set out to do with this thread. There's been allot of interest and disscusion with a few questions brought up here and in a couple new threads started as a result of this one.

It sure has opened my eyes a little wider.

Well done DD and bravo to your friend the nurse. She did an admirable job.

Thanks. I just hoped that people would read this and think about the many issues the next time they jump into the water.

I'll pass along your comments to my friend, thanks!
 
I have been away on another site for awhile, and have not seen this thread until today. But today, I read the whole thing. I have a number of things to say about the accident, but from a different perspective. I've now been in the safety profession for over a quarter century, and have used a technique from the field of product safety to analyze many accidents. It is called a "fault tree analysis," not because it tries to find fault, but because it looks from a "Systems Safety" perspective at "faults" or problems in the system being analyzed.

Before I get any further, as a former USAF Pararescueman, I must commend the nurse who provided care to this diver. Without her, there would have been no hope at all. I cannot thing of anything within her control that would have helped the situation. Had she been allowed to take the diver to the surface, perhaps the diver would have survived. Getting a heart beat back after that long was nothing short of a miraculous effort on her part.

Now, to the accident analysis. A fault tree needs to be constructed of the event. The "Top Event" was that this diver hooked into the reef and drowned. What the fault tree does is to identify each circumstance that contributed to that top event. In this case, I identified five contributing factors. Each of these factors had to be in place for the top event, the drowning, to occur. I have diagramed these out, and will analyze each from my perspective as a diver with over 40 years of experience, and as a safety professional who has applied fault tree analyses to both product accidents, on-the-job injuries, and fatality situations.

The way to complete the analysis is to look deeply at each factor and put together safety measures to ensure that the factor is controlled. Until all the issues that are identified have safety measures in place, that factor has not been eliminated.

In a fault tree, there are "and" gates and "or" gates. The "and" gates mean that the factor above it can only happen if this one factor and this second factor (to the nth factor) happen together. In other words, this and this and this must all happen for the next event to happen. This is the case with this accident. The factors I've identified are (hopefully) in the image I've attached. They include the following:

--No support
--Current (4-8 knots)
--BC Design
--Hook design
--Diver lost equipment

Each of these factors had to occur before we could have a fatal accident. In other words, if any one of these had not been present, the diver would not have drowned. I will take each factor as a separate entry. Each can be similarly diagramed out, but to save time I will simply list them.

SeaRat
 
John,

I think many of these were touched upon by the members of this board.

One item that intrigues me is "BC design". Although I'm not a fan of "poodle jacket" BC's, I'm not sure where you're coming from with this one. Can you elaborate?
 
When I say "no support," I'm not talking about a boat for a pickup, or a divemaster or instructor in the water. What I'm talking about is not having anyone immediately available for an emergency. Had someone been right with this diver, the accident probably would not have happened.

But many times, we dive as buddies and get separated in the water, if only by a few feet. Usually that is not a problem. But diving in high current means that if someone were to suddenly be tethered to the bottom, no one down-current could easily get to that person.

Absent a buddy line, the buddy system breaks down in this situation. I was trained by the US Navy School for Underwater Swimmers in Key West, Florida. During our training, we always used buddy lines. I have also used a buddy line is severe diving conditions, and they work. They keep divers together. They kept me and my buddy together on one very memorable dive when we were rolled by a huge wave, and picked up hours later by the US Coast Guard off the Oregon Coast.

Training to be a solo diver would help in this situation, as in a current dive such as this separation from the buddy without a buddy line is almost assured. A person beginning this dive should assume no support, and work from there.
 
I've never gone on a dive thinking that my buddy will save me should I get into trouble. My first thought is always am I prepared enough to save myself in the event I need help? Sure, I never dive without my buddy (who also happens to be my husband) but I think more people should depend on being able to save themselves first and using their buddy as a backup, rather than assuming their buddy will be their saviour. I don't trust my life to anyone else but myself but this isn't to say I won't ask for help should I need it. I'm extremely grateful to have a trustworthy and equally well-prepared buddy to watch my back but I refuse to insist he be solely responsible for my well-being.

Jo
 
A lot has been written in this thread about the current, and how it could not have been over about 3-4 knots. I believe it could have been higher. We have one person who observed the 4 knot current on the surface. Where bottom features would tend to channel the water, and where two different currents come together (as was stated in the original post) the current could have been greater than 4 knows.

Some have said that this greater current would tear the diver apart. No, it wouldn't. It would, however, make manouvering and small motions very difficult. I was Fin Swimming Director for the Underwater Society of America, and the fastest fin swimmer in the world has the record at just under 15 seconds for 50 meters. That's swimming at 3.33 meters per second, which is 6.4 knots (7.4 mph). That's fast, the fastest human in the water! But it won't in and of itself hurt a person. What it does is impose restrictions on what a diver can do in the water.

I've dived in rivers for over 25 years. I dive under 3 foot rapids in these rivers, and am very familiar with current diving. There is a lot that can be applied to this accident too from what I have learned about diving in current.

I noticed that the divers who used reef hooks were at an angle to the current. This provides a lot of resistance to the water, and therefore more force on the diver and the line (and the anchor--coral). While it allows them to look around, it also causes their body to create eddies in various places, and puts unusual forces on the equipment that the divers are not used to.

Current itself is not a problem. It is trying to stop in a current that is the problem. I have been tethered to the bottom in the North Umpqua River to photograph redsided shiners while they were mating in about a 4-5 knot current (it was pretty swift). I chose a 1/4 inch nylon line, and had it attached to my BC with squeeze locks you now find on backpacks. I was diving solo at the time, and accomplished this with no problems whatsoever. So the tethering can be done safely, even without support.

Many times, regular equipment is not matched well to diving in current. Large masks will leak, or be lost, much more easily thas very small volume, close-fitting masks, for instance. Also, the more equipment hanging from the diver, the more resistance to the water.

Many have discussed the "rock climbing" techniques in caves with a lot of current, without telling people why they are effective. The bottom, or in caves the sides of the caves, provide a resistance and set up turbulance that decreases the current very close to the structure. This means that, by going down to the bottom when hooked into the reef, the diver could have taken a lot of the force off the line. I regularly dived under very, very fast water and find enough turbulance on the bottom to make headway upstream. This is a skill that needs to be practiced though, and is highly discouraged on coral reefs because it damages the reef. But, when a life is at stake...

Finally, in regard to the current, the act of trying to look up, to arch one's back, or even to access one's chest will cause a tethered body to plane in the current, usually up or to the side. It will also create more force against the line she was trying to unclip. The better response would be to streamline by putting her head down, planing to the bottom, and taking the stress off the line in that manner. But, again that takes practice, and this was her first time tethered in high current (I think).

Safety Measures: familiarization with current diving, and matching the equipment to the current dive.
 
In the USAF, all the connections to our body when we were parachuting were of a "quick-release" nature. In diving, for years we used only "quick-release" buckles on our weight belts. Over many, many years, from nearly the earliest days of diving, we have preached "quick-releases" on weight belts and tank straps.

Now we have BC designs with "D" rings that we can clip into with non-quick-release clips. These can be very hazardous if there is no way of quickly unhooking in one motion in an emergency. Sometimes, like with this situation, two hands are required, one to pull slack on the line, and the other to do the unclipping.

The best backup to a quick-release is a good, sharp knife. But how many of us keep our knives sharp? In one of my Pararescue Transition School night open-water parachute jumps, I tangled my dive tanks very badly with the parachute lines. There were 32 of these lines, and a majority of them became tangled with my twin 42 tanks (I couldn't release my riser, and when the lines came down, they came down over me). I was asked by the instructors what I would have done on a real mission? I told them, I would have cut every one of those lines. They didn't believe me until they asked to see my knife (it was my own, a Sportsways made of Soligen stainless, and very sharp). After that, the issue died down. But, how many of us divers regularly sharpen our dive knives and know that they can cut us out of trouble?

Safety Measures: Use only quick release mechanisms when tethering to the bottom, and have a sharp knife.
 
If I were putting this into the fault tree diagram, there would be a box under the "Hook Design" box saying "Design Inadequate." Under that would be three more boxes:

--Cord too thin
--No Loops or Knots
--No Quick Release

I've looked at the photos shown earlier, and in my opinion the reef hooks are made with too thin a cord. It looks like nylon 550 pound-test parachute cord. This is very strong, but impossible to "climb" hand-over-hand to the anchor point underwater. It would be much better to use 1/4 inch braided nylon rope for this, and not a very thin, strong line.

To add to the ability to go hand-over-hand to the anchor, loops or knots could be put in the line. This would give a diver something to grip.

Finally, no quick release was provided. There are many ways of doing this, but they should be there. The "T" handle mentioned in many post earlier would also be a quick release.

Safety Measures--provide a reef hook with a thicker rope, loops or knots, and a quick release mechanism.
 

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