Peacock Fatality Accident Analysis

[SuPrBuGmAn]

I don't think so in this case. The girl was strong enough(despite being wrong) to follow her instincts and distrust her egress line. She didn't blindly follow along. He tried to stop her, showed her the lines, and eventually wen the way he instinctively knew was correct, not following blindly, the blind.

 

[DA Aquamaster]

This is a case where an Intro diver went 1700'ish, took several visual jumps, relying on familiarity, had a brain fart, and had ZERO infrastructure to help exit the way she came in on the dive. HUGE DIFFERENCE



I run jumps and cookie "T"s.

Let's not over state it - she made 2 visual jumps, the second back to gold line in familiar cave and she was on gold line heading out when she got confused. When you exaggerate it by saying 'several ' visual jumps and leave out some of the related information it weakens the argument.

The issue here is why did she get confused, and whether or not that confusion would have been reduced if a jump line had been in place.

Lets assume for a minute 2 full cave divers set up the circuit, then dove it on a second dive - the jump line would not have been there anyway - but we would all agree the team was always on continuos line and it would not be cited as a factor in the accident. If that were the case, what would we be saying? What is really the substantive difference here? Lets look at real substance, not just form.

In this case, the victim was not full cave (her buddy may have been) but had lots of experience as well as currency in the system and was not in an area of the cave that was particularly complex or difficult to navigate. Given the big picture of what occured, where it occurred and the victim's experience in the system, it will be a hard sell to say that the lack of a jump line 150' behind the diver on their way out on gold line would/should have made a difference.

There was a failure in information processesing and that failure is not likely to have been resolved or prevented with the jump lines in place. Had they been there, the victim, already going against the arrows on the gold line would have had to choose to leave the gold line for a smaller white lined tunnel. Had she done so she would have then faced another left/right decision at the Olsen tunnel and in either case she may have made it out with 'left' being more likely than 'right'.

However if she was not processesing information correctly or thinking rationally, taking that jump back to the crossover tunnel or not would have in essence only been a coin toss. You can argue it would have increased her chance of survival by 50%, but then you have to consider it was a similar bad coin toss, not driven by rational thought, that put her on the road back into the cave in the first place when she was already headed out on gold line only 800' from the exit. You can't logically argue it one way and ignore the other and then pick and choose what you think would have been the desired outcome.

Something happened to cause the initial cognitive error and that was the precipitating factor for the accident. The lack of a full cave cert, lack of jump lines, and possible exceeding of 1/6ths were just other factors that may or may not have contributed to the accident.

None of us will argue that doing all you can to ensure safety maximizes survival when things go wrong, but don't for a minute confuse following all the rules with an iron clad guarentee of survival. Some events, medical or otherwise, are simply not survivable and if that was the case here, then the rest is a moot issue that would have had no impact on the outcome.

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I'll call your "run jumps and cookie T's" and raise you a "cookie the exit side of double arrows". I also note times and pressures on all navigational decision points to increase SA and provide early warning if I screw up the navigational decision (thanks and credit to Mike O'Leary).

 

[LiteHedded]

DA, do you run jump lines and mark navigational decisions?

you don't have to answer if you don't want to, obviously

 

[cerich]

Let's not over state it - she made 2 visual jumps, the second back to gold line in familiar cave and she was on gold line heading out when she got confused. When you exaggerate it by saying 'several ' visual jumps and leave out some of the related information it weakens the argument.

The issue here is why did she get confused, and whether or not that confusion would have been reduced if a jump line had been in place.

Lets assume for a minute 2 full cave divers set up the circuit, then dove it on a second dive - the jump line would not have been there anyway - but we would all agree the team was always on continuos line and it would not be cited as a factor in the accident. If that were the case, what would we be saying? What is really the substantive difference here? Lets look at real substance, not just form.

In this case, the victim was not full cave (her buddy may have been) but had lots of experience as well as currency in the system and was not in an area of the cave that was particularly complex or difficult to navigate. Given the big picture of what occured, where it occurred and the victim's experience in the system, it will be a hard sell to say that the lack of a jump line 150' behind the diver on their way out on gold line would/should have made a difference.

There was a failure in information processesing and that failure is not likely to have been resolved or prevented with the jump lines in place. Had they been there, the victim, already going against the arrows on the gold line would have had to choose to leave the gold line for a smaller white lined tunnel. Had she done so she would have then faced another left/right decision at the Olsen tunnel and in either case she may have made it out with 'left' being more likely than 'right'.

However if she was not processesing information correctly or thinking rationally, taking that jump back to the crossover tunnel or not would have in essence only been a coin toss. You can argue it would have increased her chance of survival by 50%, but then you have to consider it was a similar bad coin toss, not driven by rational thought, that put her on the road back into the cave in the first place when she was already headed out on gold line only 800' from the exit. You can't logically argue it one way and ignore the other and then pick and choose what you think would have been the desired outcome.

Something happened to cause the initial cognitive error and that was the precipitating factor for the accident. The lack of a full cave cert, lack of jump lines, and possible exceeding of 1/6ths were just other factors that may or may not have contributed to the accident.

None of us will argue that doing all you can to ensure safety maximizes survival when things go wrong, but don't for a minute confuse following all the rules with an iron clad guarentee of survival. Some events, medical or otherwise, are simply not survivable and if that was the case here, then the rest is a moot issue that would have had no impact on the outcome.

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I'll call your "run jumps and cookie T's" and raise you a "cookie the exit side of double arrows". I also note times and pressures on all navigational decision points to increase SA and provide early warning if I screw up the navigational decision (thanks and credit to Mike O'Leary).

I disagree, it is far from moot. There will never be any answers as to the mental state of the deceased, as such we will never know exactly what if any bearing the lack of training had o her state.

But we can state with absolute certainty that many well established and proven cave diving rules were broken and the diver died. By itself that is enough to make following the rules make even more sense.

I see quite a few divers with the level of training this lady has do dives exactly like the one this lady died on. It unfortunately is not uncommon, but people get away with it enough that it skews the perception (of both the diving over their training and the trained buddies they dive with) of divers and it becomes an "accepted" practice.

PS-, there is absolutely NO circumstance where I am cave diving without a cont line to open water. That rule I see broken by divers who cave frequently more than any other rule. They figure the start of the main line is "good enough" and familiarity with a well dove system and easy jumps/gaps are no big deal.

 

[rjack321]

Does anyone know the gas plan & tank sizes? Was she at 1/3rds and needing to dip into the 2nd 1/3rd in order to complete the circuit exit? I am presuming she was headed out (back towards P1) on the peanut line when she panicked?

Had they done this circuit before?

 

[BabyDuck]

DA, do you run jump lines and mark navigational decisions?

you don't have to answer if you don't want to, obviously

yes he does. every time.

ok, i've said that they could have been there (800ft up peanut) without breaking any intro rules. they did, that's not part of my point, i'm not defending that they obviously broke intro rules.

but larry has a valid point, too - they could have been there without breaking full rules. (assume for a sec that they're both full.) dive up peanut, set that side of the circuit, turn & exit. or even set up both sides of the crossover. then on the second dive, go down pothole & set (or pull if you set both) the line to crossover, go through, and pull the line on the peanut side as you exit. then you're going out peanut gold line *without a jump line at crossover* (maybe with a cleanup dive left to do, maybe not) and haven't broken any rules except diving full at intro. i'm not trying to downplay rules or say it's fine to dive full at intro - i'm just trying to point out that the panic and decisions made in the panic might not have been directly related to rule breaking.

or maybe both jump lines are still there. you go up crossover in a panic, and get to your line on the olsen side. *then* the best decision is likely to go against your arrow (or cookie, or however you marked your jump) and go to olsen & out. the way you marked is the long way & you're perhaps out of gas even though you followed your lines.

yes, rules were broken, absolutely. yes, they are there for our safety & i'm not saying it's ok to break them. but don't get into the trap of 'i don't break the rules so i can never get in trouble'. if your buddy freaks out for whatever reason, the fact that you have a jump line or haven't broken thirds might not be enough. then what are you going to do?

 

[SuPrBuGmAn]

Let's not over state it - she made 2 visual jumps, the second back to gold line in familiar cave and she was on gold line heading out when she got confused. When you exaggerate it by saying 'several ' visual jumps and leave out some of the related information it weakens the argument.

I think my arguement is quite clear and there's nothing wrong with the wording I used. Several = more than one.

The issue here is why did she get confused, and whether or not that confusion would have been reduced if a jump line had been in place.

I think a line out to her exit would have been a huge factor in this incident, obviously you'd rather blame it on a medical issue.

Lets assume for a minute 2 full cave divers set up the circuit, then dove it on a second dive - the jump line would not have been there anyway - but we would all agree the team was always on continuos line and it would not be cited as a factor in the accident. If that were the case, what would we be saying? What is really the substantive difference here? Lets look at real substance, not just form.

The difference is they set it up and verified everything, likely in a timely fashion.

In this case, the victim was not full cave (her buddy may have been) but had lots of experience as well as currency in the system and was not in an area of the cave that was particularly complex or difficult to navigate. Given the big picture of what occured, where it occurred and the victim's experience in the system, it will be a hard sell to say that the lack of a jump line 150' behind the diver on their way out on gold line would/should have made a difference.

We know the victim had been up the Pothole line alot. We know the victim had been up the Peanut line alot. We do NOT know if the victim had much, or any experience in setting up jumps, circuits, or any navigation more complex than go in on one line, come out on the same line. We also know, the victim apparently had no idea where she was when the beginning of this incident took place.

She did NOT have the option to go out on the same line she went in on... an option an Intro Diver should ALWAYS have...

There was a failure in information processesing and that failure is not likely to have been resolved or prevented with the jump lines in place. Had they been there, the victim, already going against the arrows on the gold line would have had to choose to leave the gold line for a smaller white lined tunnel. Had she done so she would have then faced another left/right decision at the Olsen tunnel and in either case she may have made it out with 'left' being more likely than 'right'.

Speaking of assumptions, you're making more than anyone else in this thread.

It takes alot less mental capacity to follow a line out the way you came IMO. I know I was there a short time ago, I know I can go back through. Sure, she had been in Peanut several times, but not enough to convince herself that she was making the correct exit, which is the EXACT reason we setup jumps. Verify, physically, that we can infact make the dive.

I can keep quoting, but its the same regurgitated opinion over and over.

Does anyone know the gas plan & tank sizes?

I think it was stated earlier on she was diving doubled 85s, maybe I'm incorrect on this...

 

[TSandM]

If there was a problem, the trained response, is to follow arrows out - any exit will do...

I find this interesting. In my training, we were taught (over and over again) that the only exit you can trust is the one you came in through -- just because the arrows point to another one, doesn't mean you can get through the passage or that you can reach that exit on the gas you have (passage may be deeper or much more restricted and slow you down). In MX, you will OFTEN be on line where the arrows point away from your point of entry.

I have not had the experience of either becoming disoriented while on the mainline, or having a buddy spin and bolt on me. But I HAVE had a teammate disagree -- strongly -- with a navigational decision being made going into the cave. (It's pretty hard to disagree with navigational decisions coming back out, since they are all marked.) It's not easy to have an argument over where you are, when you are underwater. And if my teammate had been stressed or frightened, I suppose it would be even harder.

I seriously wonder if this woman, given her age, was having something going on that made her feel short of breath, and the shortness of breath made her panicky and desperate to get out. You would think that familiarity with the cave would have made her bolt in the direction of the closest exit, but perhaps not.

The other thing . . . and I throw this out there as a really scary thought, since I'm already 56 and cave diving: One of the first major symptoms of Alzheimer's disease that my father showed was confusion about where he was. He would get in the car to go somewhere, and get partway there and forget where it was he was going, or he would realize he no longer knew how to get there. It's a horrible plight to imagine, having a confusional spell in a cave, but I don't know why it wouldn't be possible. It would be interesting to know, in a macabre kind of way, if this woman's friends had noted any irregularity in her behavior over the preceding months.

Edited to add: Could someone who knows the system possibly diagram the passages, jumps, and where the victim went when she bolted? It would make the arguments about line placement clearer for me.

 

[SuPrBuGmAn]

I find this interesting. In my training, we were taught (over and over again) that the only exit you can trust is the one you came in through -- just because the arrows point to another one, doesn't mean you can get through the passage or that you can reach that exit on the gas you have (passage may be deeper or much more restricted and slow you down). In MX, you will OFTEN be on line where the arrows point away from your point of entry.

Agreed completely, trust the line you came in on above all others. I've never dived in MX, but its the same here in FL where there are multiple exits, or multiple ways to an exit.



I think wholeheartedly, she wasn't convinced she was where she should have been, and attempted to exit out her original path - which was easily missed, without the jump.

 

[ianr33]

The other thing . . . and I throw this out there as a really scary thought, since I'm already 56 and cave diving: One of the first major symptoms of Alzheimer's disease that my father showed was confusion about where he was. He would get in the car to go somewhere, and get partway there and forget where it was he was going, or he would realize he no longer knew how to get there. It's a horrible plight to imagine, having a confusional spell in a cave, but I don't know why it wouldn't be possible. It would be interesting to know, in a macabre kind of way, if this woman's friends had noted any irregularity in her behavior over the preceding months.

Thats an interesting thought.

I've only dived Peacock once. As I recall the arrows on the goldline at the Crossover jump on P1 line point towards Olsen. i.e not towards the main entrance.

If she did get confused and "forget" which gold line she was on,she may have "known" she was doing the correct thing by going against the arrows ? ?