Research Diver Fatality in Alaska

[Rollin Bonz]

It seemed to imply that the lost weight pocket knocked the mask and regulator off the diver, but I didn't understand why the weight pocket was released? Do we assume that maybe he tried to drop it when first inverted on the surface?

My thoughts (SPECULATION) were Diver 1 accidently released his left weight pocket as he attempted to disconnect his inflator hose. His assumption at the time would likely have been he was experiencing a stuck inflator valve (not realizing his double ender had actually been activating his inflator valve).

It's an incredible report/investigation. It's unfortunate that similar investigations/reports for recreational diving are not conducted/published.

 

[Rollin Bonz]

Based on the report and noted observations, I am picturing the following (SPECULATION / MY INTERPRETATION OF THE REPORT)

Diver 1 unknowingly positions himself on the bottom in such a way as the double ender on the 4th screwhole in his slate (holding his caliper) accidently activates his inflation valve.
Diver 1 realizes he is experiencing unintended suit inflation, assumes stuck inflation valve, begins to go feet up, attempts to disconnect inflator hose, in attempting to disconnect his inflator hose he accidently drops left side weights, begins to rocket to the surface, weights hit him in the face, dislodging his mask and reg, he inhales water, is unable to maintain an open airway, continues to accelerate to the surface, sudden suit expansion pops his fins and ankle weights, closed airway leads to AGE.

Is that the concensus?

Additionally, there is a section on the DAN website that reads...

Avoiding Rapid Ascents
The best way to avoid AGE and other pressure-related injuries is to ascend slowly every time you dive. Use your dive computer or depth gauge to monitor your ascent rate and conduct a slow, controlled ascent. The U.S. Navy uses an ascent rate of 30 feet per minute rule.

Rapid ascents can be prevented by using a well-maintained BCD (and drysuit, if applicable) and remembering to vent air periodically during ascent. Divers should also routinely refresh their emergency skills, such as what to do with a stuck inflator.

Proper weight distribution is also important, as one diver learned when her weight belt fell off unexpectedly. In an emergency, a diver experiencing a rapid ascent can flare out their arms and legs to create drag or try to swim away from the surface.
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It seems in this instance that this (his attempt to deal with what he assumed was) led to problems with this and Diver 1 would have been unable to do this effectively without fins.

 

[johndiver999]

Thanks for that, wasn't able to connect all the dots.

Right now, I see no reason to not accept that as a very viable explanation of a freak accident. Also, if this occurred, having a buddy 2 feet away probably would have made no difference.

 

[Rollin Bonz]

Thanks for that, wasn't able to connect all the dots.

Sure.

Right now, I see no reason to not accept that as a very viable explanation of a freak accident. Also, if this occurred, having a buddy 2 feet away probably would have made no difference.

Probably right, dropping 14 pounds and being feet up... going to be very difficult to stop that ascent unless you can grab something secured to the bottom..

I suppose, depending on the exact injuries related to the AGE (simply incapacitated, unconscious, partly paralyzed or a severe cardiac, respiratory, or brain injury), being left face down on the surface for 2 minutes didn't help.

 

[sea_ledford]

I have never seen a drysuit inflator installed in that position? I read the whole report but seem to have missed what the purpose of moving the inflation valve to the hip? Is/was that common at USC or USGS or NPS and why?

The dry suit was loaned from the USGS diver who had been working on a sea otter capture study. For that project, they were using chest mounted O2 rebreathers, which cover the traditional location of the inflator hose. In that situation the inflator is moved to the upper thigh. Look at any special forces drysuits, and they will be set up the same way.

 

[rjack321]

The dry suit was loaned from the USGS diver who had been working on a sea otter capture study. For that project, they were using chest mounted O2 rebreathers, which cover the traditional location of the inflator hose. In that situation the inflator is moved to the upper thigh. Look at any special forces drysuits, and they will be set up the same way.

I didn't see that but was reading quickly. Thanks for pointing that out.

 

[rjack321]

Thanks for that, wasn't able to connect all the dots.

Right now, I see no reason to not accept that as a very viable explanation of a freak accident. Also, if this occurred, having a buddy 2 feet away probably would have made no difference.

A buddy check might have identified the boltsnap inflator conflict though - assuming it was as obvious as the post dive analysis suggests.
Another role of a buddy beyond a second set of eyes is buddy wisdom. The ankle weights as fin keepers apparently didn't get flagged or there was a mutual assumption that the shallow depth made this kludge ok.

 

[sea_ledford]

I read the entire report and there were errors of judgment all over the place.

- Know when to call a dive
- Proper use of equipment, suspenders / crotch strap
- Proper use of equipment, LP hose to dry suit valve too short
- Diving a Dry suit without boots and rigging your fins to stay on with ankle weights
- Buddy system not followed, perhaps normal for this type of research

There was so much wrong going on there it seems unfathomable someone didn't question calling the dive. Thanks a lot for posting, as a new diver, who just purchased a dry suit, I learned a lot.

The report is confusing on actual depth of the dive, based on where they found his items I'm guessing it was only 30 feet.

I certainly won't argue with your logic here, but when the incident was presented at the AAUS symposium, you could feel the heart break through out the room. Mostly because most of the DSO's in that room had done some or most, if not all of those things at some point in our diving careers. When you remove all of the arguments of "that would never happen to me because I would never XXX!" it really hits home.

The reality of it is none of it would have mattered if his weight wouldn't have hit him in the face, knocking out his reg and mask. An inch in any other direction and it would have been an interesting end to a dive, not a fatality. It is a perfect example of the swiss cheese theory of safety protocols... sometimes all the holes line up perfectly.

 

[sea_ledford]

I didn't see that but was reading quickly. Thanks for pointing that out.

I'm not sure it was in the report, but I know that was the case.

 

[tursiops]

Too many things kludged/different. Dive should have been called.
Sad. Complacency and overconfidence not mitigated by good judgement...or by his teammates.