Research Diver Fatality in Alaska

[g1138]

Agreed, they do not show the total number of dives he ever did. But comparing LORs for those three divers, Diver 1 was the least experienced in recent scientific dives, correct?

I know he didn't have any gap other than summer between his final graduating quarter between UCSB & starting postdoc at UCSC. Same goes for when he graduated undergrad and started at UCSB. I'm not familiar with his or Diver 2 & 3's agenda of diving.

But if I made it convoluted in my last post, stated plainly he was inactive sci diver with UC Santa Cruz, while he was active with UC Santa Barbara.

Less dives, probably, considering Diver 3 had 900+; experience level I don't know.

Typically though project lead is the researcher who owns the project. So it makes sense for them to be the dive lead because they have the overall scope of the project for methods, data collection, location, & when to do it.
Typically AAUS scientific training trains you to properly use the method of diving as a means to collect data which includes leading a dive briefing and plan.

I think it's too casual of bolding the idea that he has less dives therefore is incapable of planning a dive based on least experienced diver. Whoever was the one on that team for that dive and those conditions. It insinuates he's inexperienced therefore made novice mistakes.

I think diver experienced but with complacency is my take away from the report. Usually we on scubaboard think of dive fatalities being chronic complacent but to me and our community this we defined as acute complacency. Which I'm sure plenty of us have been guilty of many times.

I think it is a very important reminder for us, even those of us with the dives above the 500 mark and years of diving number past 10.

 

[DBPacific]

For research divers there's also the pressure to get the research done - you have your funding, your project that you could've/will spend years on, the pressure to get the science done right, and in coldwater conditions, often an extra pressure to get it done right and fast before the weather turns (or the research boat goes to a different team) and you can't dive. Those pressures plus the normal stress of checks and diving (and possible tunnel-vision on your task) can be a very dangerous combination that can make you overlook or ignore issues. Goodness knows my DSO gave us enough horror stories about experienced and inexperienced divers thinking "Oh it's a problem but I need this data, so let's dive and it'll be fine" when I went through my AAUS cert.

I visited Santa Cruz pre-COVID to scout it out for grad school and there were lots of signs and memorials for Umi. He's certainly still missed by the community there. Such a tragedy

 

[tursiops]

For research divers there's also the pressure to get the research done - you have your funding, your project that you could've/will spend years on, the pressure to get the science done right, and in coldwater conditions, often an extra pressure to get it done right and fast before the weather turns (or the research boat goes to a different team) and you can't dive. Those pressures plus the normal stress of checks and diving (and possible tunnel-vision on your task) can be a very dangerous combination that can make you overlook or ignore issues. Goodness knows my DSO gave us enough horror stories about experienced and inexperienced divers thinking "Oh it's a problem but I need this data, so let's dive and it'll be fine" when I went through my AAUS cert.

Agreed. I've done some AAUS dives on my projects, and assisted with others on their projects. It is some of the hardest underwater work I've done. Nothing to take lightly.

 

[wnissen]

This is a sobering report. I'm not a drysuit diver but hope to be some day. For someone who has done a lot of challenging diving like this researcher to die in what are essentially benign conditions gives me a lot to think about. The one thing I don't understand from the report is why they assume he was hit by the weights. It seems like momentary inattention would have been enough to set off a chain reaction of events that led to panic and pulling off his own reg on the way up. Maybe I'm missing something.

 

[sea_ledford]

Goodness knows my DSO gave us enough horror stories about experienced and inexperienced divers thinking "Oh it's a problem but I need this data, so let's dive and it'll be fine" when I went through my AAUS cert.

Yes, data collection focus is a serious concern. If at all possible, I insist that the lead diver is not the Primary Investigator, because the PI will almost always err on the side of collecting in judgement calls. See the pages and pages of vitriol on the divers that collected at Blue Heron Bridge to see an example of a non-fatality incident of this.

Normalization of deviance also played a part in this. He had already conducted a dive in the exact configuration, with no issues. Having to completely de-gear to put on his suspenders in a tiny boat was decided to not be worth the effort and/or a higher risk.

Sounds like (and was) a horrible decision with hindsight, but imagine hiking down a steep coastline in full gear to do a beach dive then realizing you left your knife in your car a 1/2 mile away. Do you call the dive and go back to get it, or do you do the dive without your knife? Most divers would do the dive without the knife, I imagine. And if they died because they were entangled and didn't have a knife... Be careful of hindsight bias.

-Chris

 

[Hiszpan]

Yes, data collection focus is a serious concern. If at all possible, I insist that the lead diver is not the Primary Investigator, because the PI will almost always err on the side of collecting in judgement calls. See the pages and pages of vitriol on the divers that collected at Blue Heron Bridge to see an example of a non-fatality incident of this.

Normalization of deviance also played a part in this. He had already conducted a dive in the exact configuration, with no issues. Having to completely de-gear to put on his suspenders in a tiny boat was decided to not be worth the effort and/or a higher risk.

Sounds like (and was) a horrible decision with hindsight, but imagine hiking down a steep coastline in full gear to do a beach dive then realizing you left your knife in your car a 1/2 mile away. Do you call the dive and go back to get it, or do you do the dive without your knife? Most divers would do the dive without the knife, I imagine. And if they died because they were entangled and didn't have a knife... Be careful of hindsight bias.

-Chris

Agree about suspenders. But to fasten a crotch strap you don't need to remove all gear.

 

[lv2dive]

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

Yep I missed that too - and also appreciated the explanation.

 

[g1138]

This is a sobering report. I'm not a drysuit diver but hope to be some day. For someone who has done a lot of challenging diving like this researcher to die in what are essentially benign conditions gives me a lot to think about. The one thing I don't understand from the report is why they assume he was hit by the weights. It seems like momentary inattention would have been enough to set off a chain reaction of events that led to panic and pulling off his own reg on the way up. Maybe I'm missing something.

It was the most likely speculation based on the short timing since the last sighting of the diver with his last know body trim/position. Also giving into consideration that the diver's experience precludes panic induced reg and mask ditch.

The likely catalyst of the fatality was the inadvertent inflation of his drysuit by his slate's double-ender. This would be interpreted by the diver as an drysuit inflation malfunction which given his body trim would put him in an inverted ascent. The correct response would be to tuck and roll but also disconnect the drysuit inflator.

Tuck and roll would be impossible given lack to drysuit suspenders, lack of drysuit crotch strap, lack of dry suit booties, leading to fin pop-off.

Since his mask & left weight pocket were missing; left being the side his drysuit inflator was at, it is assumed that while trying to disconnect his inflator (while inverted) he pulled his weight pocket which dislodged both mask and reg leading to the breath hold on ascent which led to AGE.

It is further speculated that the water intake from loss of mask and reg, while inverted would cause the diver to spasm and close his air way. So it's a mute point to speculate whether he tried to keep his airway open or not.

 

[Mermaid Avenue]

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 am just wondering who made Diver 1 a Dive Leader on that particular dive. Diver 3 was much more experienced judging from the bio provided. It looks like there was a lot of tasks assigned to Diver 1, who was the least experienced. Protocols should be reviewed.

I was really frustrated by the description of Diver 3's lack of attention to the remaining divers in the water (i.e. facing away from the transect area). If he had been watching bubbles immediately after entering the boat, he would have seen Diver 1 when he hit the surface. Since the team lacked (what I believe to be necessary) a topside tender, watching bubbles should have been his first priority.

 

[Mermaid Avenue]

It was the most likely speculation based on the short timing since the last sighting of the diver with his last know body trim/position. Also giving into consideration that the diver's experience precludes panic induced reg and mask ditch.

The likely catalyst of the fatality was the inadvertent inflation of his drysuit by his slate's double-ender. This would be interpreted by the diver as an drysuit inflation malfunction which given his body trim would put him in an inverted ascent. The correct response would be to tuck and roll but also disconnect the drysuit inflator.

Tuck and roll would be impossible given lack to drysuit suspenders, lack of drysuit crotch strap, lack of dry suit booties, leading to fin pop-off.

Since his mask & left weight pocket were missing; left being the side his drysuit inflator was at, it is assumed that while trying to disconnect his inflator (while inverted) he pulled his weight pocket which dislodged both mask and reg leading to the breath hold on ascent which led to AGE.

It is further speculated that the water intake from loss of mask and reg, while inverted would cause the diver to spasm and close his air way. So it's a mute point to speculate whether he tried to keep his airway open or not.

There is one thing that would have mitigated and possibly avoided this disaster, and that is if Diver 1 had added a ziptie to his double ender and thus a jointed addition to his slate. Had he done so, it is unlikely that the double ender would have aligned with the inflator button.