Lessons to be learned-Death in Palau

[John C. Ratliff]

When we were making parascuba jumps, it was the jumpmaster who was tasked to make equipment checklist inspections to ensure that we were jumping with the right equipment. When we jumped into the windstream of an HC-130, there was a huge blast of air, more than any current, yet we kept our fins on. How? We taped them on with masking tape. Masking tape comes off easier than duct tape, but will hold equipment on.

The diver who drowned lost both her mask and one of her fins.

If the fins had been taped on, they would not have come off. If someone had checked the tightness of their fit prior to the dive, it would not have come off.

The mask is a different situation. We don't know what kind of mask it was. If it was a larger mask, then it would be more likely to come off in the current. Also, if it was worn loosely, it would be more likely to come off.

 

[John C. Ratliff]

Again, I need to point out that a "fault tree" analysis is not about finding fault. I once had to change the name one time to "Logic Tree Analysis" to take the word "fault" out of the picture. What I attempted to do was to isolate the contributing causes of this accident, then look at all the factors that could have played a role in that factor. Because we may never know the exact nature of the event, we need to act on each one of these with safety measures that have been developed.

My hope is that by going through this exercise the type of drift diving being conducted by the various groups could be modified to make it safer.

In the Product Safety realm, we are very concerned about "single-fault" accidents. These are accidents where one single failure could be catestrophic. Please note that in this accident, it took five faults (problem areas), occurring together, to make the accident.

Now, just a note on the possible cause of death by drowning. Many of the people who posted here cannot see how a diver with a regulator that was functioning in her mouth could have drowned. There are at least two possible explainations I can think of:

--That the regulator became dislodged after our nurse/diver helped free her on ascent.

--That the diver suffered a spasm of the larnyx (salt water in the throat can cause that), and was unable to breath, and then when she tried aspirated through her nose. The water then had a pathway to the lungs through the nose, even with the regulator in her mouth.

To see how easy this would be, try this the next time you are at the pool. Put your head underwater, and put your mask on without clearing it. Keep the water inside it. Then, lay down on your back out of water, and breath through your regulator. In the Underwater Swimmers School, we had to do flutter kicks on our back, laying on our double-tank rigs on the pool deck with that mask full of water pointed up into the air. We also had to sing at the same time. Try it to see how it feels, and you may get an idea of what this young woman went through on the bottom. By the way, if we couldn't do that, the Navy would have flunked us out of the school because we would have shown that we couldn't control the nasal opening between our nose and throat. All who graduated were able to do that exercise.

Please also realize that no one accident analysis technique holds all the answers. I have used the fault tree analysis technique to isolate those factors I could identify from reading all the posts on this thread. But what this does do is force us to see beyond our own, sometimes limited perspective, beyond the "blame game" I saw beginning to take hold, and into the possible contributing factors and their safety measures. I hope this helps the discussion.

SeaRat

 

[Seadeuce]

Hi,
I am new to this forum, but not new to dive instructing, diving, and diving in currents.

When someone tragically dies apportioning blame is a natural reaction. We all do it.
In the incident described above, this lady was - as unfortunate results were to prove - unable to cope withe the situation she found herself in.
I believe she was certified; as were the other divers on the liveaboard.
I have a problem - in fact TWO problems here:

ONE - why do Dive Charter companies/tour operators advertise "Advanced Diving" in their brochures for places like Palau? Then they accept OWD/AOWDs onboard and expect them to dive safely.
This is not a recent phenomenon; when I visited Palau a number of years ago, on a different liveaboard to the one mentioned in this incident, I found myself buddying a diver with only 30 dives done. Yet I had chosen that boat for its "Advanced Diving" facility.

At least, the boat did not allow us to dive Peleliu, the Cut, nor Siaes Tunnel. I and others missed out on good diving because of the lack of experience in some of the divers aboard. But we had no incident in the week I was there. The skipper made the right call under the circumstances, but quite obviously was party to the acceptance of less-qualified-than-advertised-for divers.

MESSAGE - All vacationing divers need to accept that the diving - and the buddies - can be a whole lot different than expected.

TWO - why is it generally accepted that being "certified" makes one a diver?
Diving agencies (commercial ones, that is) have profit as their goal, and in so doing inadvertantly, and I say that with deliberate sarcasm, misinform their students.
Do a course, get the C-card, you're now a diver!
The courses contain all "positive" points of diving. They don't mention the negatives.
It takes a few years to learn that there's a fine balance between the positives and negatives of scuba diving. If more people were educated as to the REALITIES of diving, they may be better prepared to handle - and to judge - situations that may have been avoided in the first place, had they some prior knowledge.

MESSAGE - Agencies will show you how to dive; that does NOT mean they will make you a diver!

My condolences to the husband and family of that lady who perished, and that nurse deserves all our applaudits for an excellent piece of work, considering all circumstances.

My apologies for my longer-than-planned-for .02 cents, but I have seen the above too often, and in too many places, to let this discussion - if you will pardon the pun - "off the hook"


Sincerely,


Seadeuce

 

[detroit diver]

Seadeuce,

First of all, welcome to the board!

Second, I think you will make a fine addition to this board, as your post clearly shows. Many of us believe that the scuba training has really been watered down to the point of being dangerous. Others, of course, disagree.

Dive safe,

Jack

Seadeuce once bubbled...
Hi,
I am new to this forum, but not new to dive instructing, diving, and diving in currents.

When someone tragically dies apportioning blame is a natural reaction. We all do it.
In the incident described above, this lady was - as unfortunate results were to prove - unable to cope withe the situation she found herself in.
I believe she was certified; as were the other divers on the liveaboard.
I have a problem - in fact TWO problems here:

ONE - why do Dive Charter companies/tour operators advertise "Advanced Diving" in their brochures for places like Palau? Then they accept OWD/AOWDs onboard and expect them to dive safely.
This is not a recent phenomenon; when I visited Palau a number of years ago, on a different liveaboard to the one mentioned in this incident, I found myself buddying a diver with only 30 dives done. Yet I had chosen that boat for its "Advanced Diving" facility.

At least, the boat did not allow us to dive Peleliu, the Cut, nor Siaes Tunnel. I and others missed out on good diving because of the lack of experience in some of the divers aboard. But we had no incident in the week I was there. The skipper made the right call under the circumstances, but quite obviously was party to the acceptance of less-qualified-than-advertised-for divers.

MESSAGE - All vacationing divers need to accept that the diving - and the buddies - can be a whole lot different than expected.

TWO - why is it generally accepted that being "certified" makes one a diver?
Diving agencies (commercial ones, that is) have profit as their goal, and in so doing inadvertantly, and I say that with deliberate sarcasm, misinform their students.
Do a course, get the C-card, you're now a diver!
The courses contain all "positive" points of diving. They don't mention the negatives.
It takes a few years to learn that there's a fine balance between the positives and negatives of scuba diving. If more people were educated as to the REALITIES of diving, they may be better prepared to handle - and to judge - situations that may have been avoided in the first place, had they some prior knowledge.

MESSAGE - Agencies will show you how to dive; that does NOT mean they will make you a diver!

My condolences to the husband and family of that lady who perished, and that nurse deserves all our applaudits for an excellent piece of work, considering all circumstances.

My apologies for my longer-than-planned-for .02 cents, but I have seen the above too often, and in too many places, to let this discussion - if you will pardon the pun - "off the hook"


Sincerely,


Seadeuce

 

[The Chairman]

and please feel free to post your 2 cents as long as you please. I agree with pretty much everything you said there.

 

[DeepSeaDan]

Seadeuce said:

"If more people were educated as to the REALITIES of diving, they may be better prepared to handle - and to judge - situations that may have been avoided in the first place, had they some prior knowledge."

I spend cosiderable time with my entry level students discussing the need for conservatism & I punctuate these talks with case studies of incident/accident analysis & a liberal sprinkling of personal anecdotes.

The result is a sea of sober faces staring back to me.

Students must be made to realize they are becoming involved in a sport that can be very unforgiving to the ignorant, the brash & the unwary.

Not to say the course is all doom & gloom; on the contrary, equal time is devoted to the unique wonder of the diving experience...it is simply a question of balance.

Crawl before you walk...walk before you run...& always respect where you are when you are.

Regards,
D.S.D.

 

[Seadeuce]

This lack of "Reality Education" permeates the rank and file of most agencies. Now, don't get me wrong - I'm not anti-this agency or anti-that agency, enough has been said about that topic in other newsgroups without any constructive conclusion.

To illustrate my point I will mention just one personal experience.

I am an Extended Range diving instructor, qualified to teach and dive to 51m (167ft) on air.

I went on a week's liveaboard to the Brothers, Elphinstone Etc., last year, in the southern Egyptian Red Sea. Towards the end of the week, when our divemaster assumed we were all dived up, he said we could do a "deepie" on the Numidia wreck.

The group onboard were a mixed bunch, some had over a thousand dives done, others less than sixty, ranging from top-level instructors to AOWDs, and one OWD.

Three of us went to the stern of the wreck at 54m (177ft), others we met at 48m on the way back up.
Earlier in the week I had touched 50m on the reef, and the DM had pulled me aside and asked me t stick to a 40m maximum depth. Okay to that.

After the wreck dive, he said we three had seriously exceeded safety limits by going to the stern of the ship. I didn't reply.

At the end of the week, which I thoroughly enjoyed, we were having our "final debrief" at Papa's in Hurghada. During our course of conversation, the Numidia was mentioned by one of the other divers in attendance.

The DM extolled the virtues of the wreck, and the site itself. Then I said my piece.

I mentioned, nice and politely, that diving on remote reefs and wrecks has a certain allure, and the approach to diving same should be based on safety first, diving ability and qualifications second. He agreed.

I then said that on two occasions he had spoken to me on my exceeding the limits of safety. He said yes.

I said that at the beginning of the trip I had shown him my logbook, with the Extended Range qualification, and proof that I had been actively diving in home waters before the trip. He remembered.

I reminded him that, on the ascent back up the wreck, we had passed two AOWDs at 48m, another one at 42m. The OWD was around 37m with his buddy.

I told him that the 40m limit was an arbitrary depth limit picked by the founding fathers of commercial agency diving, not a limit based on scientific analysis of the effects of physics, table algorithms, or any other factual evidence.

On our dive on the Numidia I had exceeded my qualification by one depth increment. Other divers had exceeded theirs by six!
When assessing diver ability, I said the baseline for competence should be Rescue Diver. At least then a diver has some idea of self-rescue if a situation arises.

The baseline should not be certification, nor an arbitrary limit of 40m. I suggested DMs should make it a point to get to know what diving each individual does as his/her norm, and pair off similar profiles if possible. Then, on a "deepie" a DM should ask if the divers with depth experience would buddy up with those of less experience.

The conversation changed subject, and we had a good final night.
The following morning, on our leaving the boat, the DM came up to me, shook my hand and said thanks, he'd learned something this trip. I said I was glad to help.

Our sport is a fascinating one; it can excite and enthuse, de-stress and delight. It can also humble.
But it never fails to inform.

When the mind is closed to learning, complacency sets in. That's when our mutual friend Murphy rears his head.

Thanks for taking the time to read.

Seadeuce


Last dive: April 23rd, Oilean na nEasc. 31m - 50mins. Water temp. 50 degs.

 

[Wife of victim]

As the wife of a diver killed on the Wave Dancer, I can answer the question about the number of victims we know about so far. 17 innocent people were killed on the Wave Dancer, and now this victim in Palau. And, let us not forget the shark attack victim off the Sea Dancer off the Turks and Caicos Islands, who was very severely injured, and according to reports, may never regain full use of her arm. I find it especially interesting that the nurse who saved (albeit temporarily) the Palau victim had to get the medical supplies needed from the Aggressor boat. Where they not on the Dancer boat? Obviously, no crew member knew how to use them anyway. It is not the diver's responsibility to be allowed to be taken to a dive site they are not trained or briefed for. Also, 17 divers, and 1 divemaster??? Completely impossible to safeguard that many people. If anyone is interested, I have a copy of the many safety failures of the Wave Dancer that contributed to the capsizing, not to mention the incorrect docking, and the too-tight lines that snapped. And, there is the issue of the captain and second captain being in a life boat, while the passengers were trapped and abandoned to drown. Any and all questions, please ask. I want everyone to know as much as I do. Of course, I don't know everything, as the 3 survivors have refused to give any information. So, as far as we know now, 18 symbols need to be painted on the boats. What should those symbols be??? Thanks for listening.

 

[jepuskar]

:frownshk: :frownshk: :frownshk:

 

[Seadeuce]

My condolences for your sad loss, more sad because it was avoidable.

Just one point, in my previous post I mentioned having been in the Red Sea last year. In our initial briefing aboard our boat we were told by the DM, somewhat tactlessly in my opinion, that in the previous ten days there had been eight deaths in the Northern Red Sea.

With upwards of 2,500 boats there, the diving population has exploded over the past few years.

However, my point is that these "accidents" happen across the dive spectrum, and are not confined to individual ares, or indeed operators. They are very often the result of a poorly-marshalled training and education regime.

Unfortunately, these events will more than likely increase in number with the popularity of the sport, and the lack of health and safety procedures/ greed of some of the dive dons.

Via con Dios.


Seadeuce