Peacock Fatality Accident Analysis

[Dive-aholic]

Bob, she was 200 feet from the breakdown room. The arrow at the bottom of the slope is the 600' marker. You're exactly correct.

 

[TSandM]

So the body was found where the panic began? So she bolted backwards, at some point recognized her error, turned around, and just couldn't make it out? What a horrible scenario.

I think it would be a terrible thing to be in a cave with a panicked buddy who was insisting on going the wrong way. I think I would try to restrain the person physically, but adrenaline is powerful stuff and I might not be able to do so -- and I can EASILY imagine that a struggle in a cave could result in zero viz, making the whole thing much, much worse.

This is one of those things, like an incapacitated buddy with a deco obligation, where I don't think you can really know what you can do or what will work until you are there. I really, really feel for this woman's buddy, even though they broke rules. He faced something I hope I never do. I wonder if he will cave dive again.

 

[ucfdiver]

So the body was found where the panic began? So she bolted backwards, at some point recognized her error, turned around, and just couldn't make it out? What a horrible scenario.

I think it would be a terrible thing to be in a cave with a panicked buddy who was insisting on going the wrong way. I think I would try to restrain the person physically, but adrenaline is powerful stuff and I might not be able to do so -- and I can EASILY imagine that a struggle in a cave could result in zero viz, making the whole thing much, much worse.

This is one of those things, like an incapacitated buddy with a deco obligation, where I don't think you can really know what you can do or what will work until you are there. I really, really feel for this woman's buddy, even though they broke rules. He faced something I hope I never do. I wonder if he will cave dive again.

It's pretty hard to silt out Peacock mainline. One of the "good ole boys" teaches an optima course at Peacock and lets his students crawl around on the floor while kneeling at the crossover tunnel to put in a jump, and even that doesn't get zero viz.

 

[LiteHedded]

It's pretty hard to silt out Peacock mainline. One of the "good ole boys" teaches an optima course at Peacock and lets his students crawl around on the floor while kneeling at the crossover tunnel to put in a jump, and even that doesn't get zero viz.

agreed. it would take a lot of work to make those bits of cave zero vis.

 

[cerich]

agreed. it would take a lot of work to make those bits of cave zero vis.

naw, just turn off your lights...

 

[parabuzzle]

This is just my 2 cents from a psychological point of view. If you follow all the rules then you are less likely to second guess yourself. Think about it. If you break 1 or 100 rules, it will be something to later "eat away" at you if something goes wrong or you second guess which way is out. I think that, if you had followed all the rules (placed reels on the jumps, placed cookies, etc) you would not only have items to reassure and verify when that wave of confusion or second guessing hits but you will also have psychological reassurance to help you in knowing that you didn't break any of the rules so your second guessing must be unfounded. This psychological reassurance would be enough to get you to a point where something physical (like the breakdown room) would then reinforce the decision.

 

[DA Aquamaster]

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

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

Yes I do. Every time. I've even put line in for the 18" jump to the Pothole line. It feels a bit silly to do it, but it's a matter of principle. I also run a continous line at Ginne which puts me in a clear miority of cave divers I see there.

Obviously I believe in stacking the deck in my favor.

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.

The problem with the logic that:

"rules were broken and a diver died, therefore the breaking of the rules resulted in a death"

is that it fails to consider the thousands of visual jumps that have been done on that very same circuit where breaking the rules did not result in a death. To make that logical statement accurately, you have to consider the entire population of dives where rule breaking occurred - including dives where diver got away with it, whether we like it or not.

I'm not definitely not saying breaking rules is smart or justifyable.

I am saying that breaking the rules in this case is not the most likely cause of the accident. They may or may not have been contributing factors, but given the number of dives the team had done there and their experience level, separate form certification, the odds are good that breaking the rules did not precipitate the incident or cause the obvious disorientation and panic.

Look at it in terms of what we would be saying if the dive where the fatality occurred had been dive number two of a properly executed circuit done by full cave certified divers where no rules were broken (dove within thirds, pulled the jumps as dive two progressed, then suffered the same incident on the peanut line 800' from the P1 exit. What would we be saying then?

Again, the areas of concern that would be common for both dives are the areas that are most likely causative in the accident that did happen. By looking at it this way you are in effect controlling for the non fatal variables.

Given what we know and:

1. the experience of the divers in question
2. the number of dives in what is a large and easy to navigate portion of peacock
3. with the divers on gold line headed out only 800' from the exit
4. And also considering the thousands of safely completed dives where visual jumps have been made there (right or wrong it is a fact that is sadly true)

It then defies logic to place the blame for the accident solely on the following broken rules:

1. Diving beyond the victim's cert level (i.e would the victim having a full cave cert have prevented the death? How would she have fared as a newly minted zero to hero full cave diver compared to an intro diver with 5 years and hundreds of dives, many of them in those very tunnels?)

2. Possibly exceeding 6ths (many divers with full cave certs but far less experience do the same dive on thirds, and the half way point was probably and certainly can be reached on 6ths. Plus the buddy had ample gas to exit the way they entered and hold for a substantial period of time at pothole waiting to see if the buddy appeared there.)

3. Not maintaining continuous line to the exit. (we can split hairs here regarding verified line, how long a lapse can be considered between verifying one side of the curcuit before you complete it, and whether being on the gold line 800' from your intended exit constitutes continous line or not. But the reality is they had a continuous line to open water - not counting the 2' from the end of the peanut line to OW where virtually no one, including myself places a primary unless they are in a class - and it did not prevent the fatality.)

When rules are broken it can and often does set up a domino effect where a survivable emergency becomes an unsurviveable situation, but in that case the broken rules form a clear chain of events that led to the death and would have clearly prevented the death had the rule not been broken. That level of clarity is lacking here and a reasonable person looking at it from something other than a dogmatic or authoritarian argument would have to consider what precipitated the inital confusion and whether any or all of the rules clearly would have prevented the fatality. I don't think the facts as we know them can support that conclusion.

 

[Cave Diver]

Yes I do. Every time. I've even put line in for the 18" jump to the Pothole line. It feels a bit silly to do it, but it's a matter of principle. I also run a continous line at Ginne which puts me in a clear miority of cave divers I see there.

I'm with you on that. Sometimes it seems silly but my thinking is that if I get in the habit of breaking one rule, I'll find a reason to break others. I won't say that I've never broke, or at least bent one before but it's definitely not the norm for me.

 

[lamont]

the rules are important. all dives i've been on that included jumps put in a line. i'm not advocating blowing off the rules or saying they don't matter.

BUT - a panicking intro diver at 800ft in peanut is possible without rule breaking. don't get hung up on the broken rules being the cause of this problem. let's think of things to do if our buddies act irrationally, or what we would do if our buddy takes off & we can't catch them, or how to convince a buddy that they are going the wrong way instead of following the red herrings of either the rules or unproven medical issues.

If you have gear that you left on that dive confirming your exit, it will give you more information and calm you down in a way that a permanent navigational marker in a cave will not.

I sometimes swim against the permanent navigation markers in a cave on exit. I never go back the way my (teams) gear isn't pointing. Ever.

So, yes, failure to establish a guideline was a critical part of this accident chain and one that I strongly believe could have prevented it.

And, no, I've never broken the continuous guideline rule. Its an idiotic rule to break. Take the time to put in a spool or a reel and drop cookies at Ts.

The rules are not a "red herring", the rules are how you *prevent* getting into this situation. Once you've got a buddy in a panic swimming the wrong way you are pretty screwed, the point is to break that accident chain long before it gets there -- and all the continuous guideline rules help to prevent getting that far into the incident pit.

Honestly, the position that the rules are a "red herring" is seriously dangerous complacency. I'm sorry, but if you want to have an honest discussion about this it *begins* with violation of the continuous guideline rule. If you want to prevent this, start leading by example and *stop* going into these systems without proper guidelines just because everyone else does it. Stop using excuses.

 

[BabyDuck]

i hope those are general 'you's & not directed at me, since i always put in jumps.

i'm not complacent about the rules. i don't believe they're there to be broken. i just don't buy that rule breaking in this case is a direct cause of this fatality. contributory, perhaps.

i assume (eek!) that the only reason we know that they did this visual is the buddy confirmed that. what if he hadn't said? perhaps then we'd be thinking they put in the jump on a set up dive & pulled it coming out. she bolted *150 feet* from that jump. if she was worried about the navigational decision from crossover to peanut, that was the time to discuss it with her buddy until both were satisfied. whatever warm fuzzies she could have had about that decision when pulling the jump were gone, for whatever reason. yes, she'd still be doing a full dive on an intro card and very likely breaking sixths, but perhaps not if she had a phenomenal sac rate - she had enough gas to get out of most of the sinks in the system as it was if she'd picked one & headed to it.

not having that jump in place did not help. but it did not necessarily *cause* this problem. in a normal textbook circuit, it would have been pulled and therefore that line would not have been there when she turned back.

if you get to where your cookies & line are supposed to be by your remembrance & they aren't there, is your first action going to be to haul off the other direction as fast as you can go? no, i don't think that's what you'd do. you'll communicate with your buddies until everyone's satisfied.