Peacock Fatality Accident Analysis

[DiverLaura]

This answers a question i didn't have time to ask yesterday.

You can have done the same dive 1000 times, but when you add a 'new skill' to the mix it changes the game.

In my very limited cave experience (though i do have a bit of experience on wrecks), things look different from the other direction, ESPECIALLY if you've taken snapshots on the 'way in' or for the majority of the dives seen the route from the 'other direction'.

adding jumps and circuits is not a small decision/small step 'up' in my mind. no matter how many times they'd previously dove the system.

in my class we did a lights out drill in peacock RIGHT after a point where the arrows switch direction. I made a note of it in my head about 30 seconds before the lights went out, but i gotta say, grabbing line and feeling the arrows point 'contrary' to what your brain is thinking, and hoping the next one you feel is the middle mark is a very long 15-20 seconds and actually made me think back and question myself for a split second. I can very easily imagine if she took her eyes off the line for even a little bit looking for 'recognizable landmarks' and not seeing things look how she expected them to look (from other direction) how looking back down and seeing the arrows going contrary to what the brain thinks it should be seeing could start a spiral of doubt. Sometimes that's all it takes.

Someone told me a story about doing the catacombs at Ginnie without a guideline. "oh, i'm really close to the exit and i've done it tons of times" and then after they finally found their way out, referring to it as the dive where they were absolutely SURE (in their mind) they were gonna die.

While they had been diving this site weekly for a number of years they had only recently started doing jumps/circuits(somewhere in the past 8 months or so). I also know of another dive while still p400' on the olsen line she bolted past other divers in the team, in that instance she had gotten confused about the location of one team member, and thinking she was ahead poured on the speed(leaving the diver she was looking for behind) and this was with no communication whatsoever, just suddenly passing and hauling ass off into the distance. Also both divers had intro cards.

 

[rjack321]

Not to say its right... but the Peanut line is literally 3' from OW, there's no sorta to seeing daylight there.

Ok you know FL more than me. Seemed a little further than that to me (like 30ft), but I was only there once so maybe I'm mixing it up with the image of some other 90deg "left hand" tunnel in my head.

 

[DA Aquamaster]

Exactly! The proximate cause of the panic was lack of personal references in the cave, jump spools, arrows etc.

That is a wild ass assumption. It would never stand up in court as you have absolutely no way of knowing another person's state of mind and specifically in this case why she became confused and/or panicked.

I agree that had they been setting up a circuit and she had bolted that she coudl have them come across their own jump reel and had the potential to know where she was in the cave. However, Marci's point is that even if you followed the rules, if they were on dive 2 of the circuit and pulling the gear behind them, there would have been no perosnal gear to see when bolting in a direction believed to be "out".

Your assumption that having properly placed jumps woudl have conveyed a sense of confidence or reduced confusion is not idealistic and not very plausible. This was not mexico and it was not new cave for the diver. It is the peanut tunnel, with compartively simple navigational demands.

More importantly a cognitive error occurred (medical, exceeding her limits or otherwise) that led to her bolting, apparently in a panic, and she continued to make errors.

Looking at a map, it is evident that she bolted at a point 800' from P1 on the Peanut line, about 500' from Olson, 1700' from P1 via the crossover and olsen-pothole lines, 1400' to Olsen via the peanut restriction and about 1800' from Challenge. If her gas consumption was comparabel to her buddy's consumption she ahd enough gas to reach any of those exits if she just stayed the course.

Asumiming she got to the peanut restriction and realized where she was (with apparently enough gas to go another 1000') she had 3 chouces. Left and 800' to Challenge, right and 500' to Olsen, or back track about 1800' to P1. Only one of those choices would have resulted in death yet that was the choice she made.

Obviously several minutes after bolting, she was still not processessing information well and could not assess and/or effectively utilize the resources she had left.

The point being that in a full panicked or confused state that lasted at least 10 minutes, she would have most likely not benefited from seeing a jump real at the crossover tunnel.

What is left is whether not breaking the three rules that were broken would have made a difference and all we can do is speculate about that. If it was a stroke, TIA, pre-alzheimers siutation then the answer is probably not.

Absolutely no one is arguing that breaking the rules was smart, and breaking them clearly did not help the situation, but that is different than saying they were the cause of the accident. At best that is just one more supposition with no more weight or merit than suggesting a medical factor precipitated the chain of events.

Those of us suggesting we need to look beyond the rule infractions are saying exactly that. We are not mimimizing the infractions but rather are just suggesting there is benefit in looking at the entire picture to ensure nothing gets missed. If you just assume the accident would not have happened had all the rules been followed, you then run the miss of missing another unrelated causative factor and in turn run a risk of learning nothing from her death.

 

[MXGratefulDiver]

Ok you know FL more than me. Seemed a little further than that to me (like 30ft), but I was only there once so maybe I'm mixing it up with the image of some other 90deg "left hand" tunnel in my head.

It's been moved during the past few months. When I was there last August, the beginning of the Peanut line was further inside. When I returned in November, it had been moved so that it's literally within an armspan of the entrance ... as is the Mainline. What I was told when I asked why is that it was due to environmental concerns. Someone also told me that there's not solid agreement among those who are responsible for making such decisions that it was the right thing to do.

... Bob (Grateful Diver)

 

[ucfdiver]

Not to say its right... but the Peanut line is literally 3' from OW, there's no sorta to seeing daylight there.

A rule is a rule, Mathew.

 

[rjack321]

Absolutely no one is arguing that breaking the rules was smart, and breaking them clearly did not help the situation, but that is different than saying they were the cause of the accident. At best that is just one more supposition with no more weight or merit than suggesting a medical factor precipitated the chain of events.

Ever heard of Occam's Razor?

While she was in her 60s, she had a pattern of similar "irrational" tunnel vision behavior in the past. Adding layers of medical justifications, shortness of breath, heart attack etc, leading to her panic is a) untestable b) not required c) statistically unlikely.

 

[Cave Diver]

It's been moved during the past few months. When I was there last August, the beginning of the Peanut line was further inside. When I returned in November, it had been moved so that it's literally within an armspan of the entrance ... as is the Mainline. What I was told when I asked why is that it was due to environmental concerns. Someone also told me that there's not solid agreement among those who are responsible for making such decisions that it was the right thing to do.

... Bob (Grateful Diver)

It seems like lines move around a lot down there.

 

[ucfdiver]

It seems like lines move around a lot down there.

Every time I've been to Peacock in the past 3 years the Peanut line has been right at the cavern zone. In Basic/Apprentice, I had to run the reel around goldline beyond the sign because it was too close to count for reel work in class. I think most instructors have students do this.

 

[Cave Diver]

Every time I've been to Peacock in the past 3 years the Peanut line has been right at the cavern zone. In Basic/Apprentice, I had to run the reel around goldline beyond the sign because it was too close to count for reel work in class. I think most instructors have students do this.

It's probably been that long since I did Peacock, but it seemed for a while there the line moved several times. If I recall correctly the last time I was in there the line was practically in open water.

 

[rjack321]

I haven't done many circuits but the few I have done required us to "commit to our new exit". Ie. when we reach our special cookie marking our setup penetration we give a index finger pointing to new exit thumb up signal (easy to show hard to describe). This means "we are exiting ahead" and in the event of some issue (gas, lights etc) we are not turning around anymore to exit.

I don't do visual jumps but how would these divers have "committed to an exit"? Could the apparent lack of this committment have factored into her confusion and eventual panic?