Russia - instructor caused divers death
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Tigerman
Contributor
Thanks.Color adjusted... Next time someone will tell me they prefer to only read in lavender tone...
It made it a lot easier on my eyes (bright text on bright bg is frowned upon in design), but it seems babelfish has a lot of improvements to be made
It kinda seems to me that the biggest errors might not have been done by the DI, but if hes "missing" thats kinda worrying. He might have just paniced because of the outcome and fled, or there might be something less obvious that he dont feel like being question about..
jviehe
The name of the DI WAS was published publicly.
On the police report, on 3 various webboards.
StreetDoctor
Not reason to freak out for you or for me or anybody else with gazillion of ice or cave dives but russian instructors in general are pushing the limits in order to make and extra buck, aside of some agency offices selling instructors licences like russian IANTD office does, certifying cave instructors who teach full cave in the pool or teaching divers its ok to get in the water with 4 cilinder with 50 bar in each of thes coz the total pressure is 2000bar which is just enought for diving. then when they kill someon during the course - not their fault.
People TRUST their instructors andinstructors don't care about that.
Tigerman
yeah, they are bad divers in general because they have been taught to act that way, coz their instructors teach them how to qualize, how to go down and up and how to use diving computer. and thats it.
mts0628
that means - last sunday
wilde100
proper translations:
Past Sunday, on July, 12th, in Spas-kamenskii lake [name removed], diving in a group of 4 divers under the direction of freelance instructor [name and # removed]within the limits of course AOWD went missing under water. All the previous day, on July, 11th, the group in the same structure has made 3 dives with [name removed] to depth of 17 m. On July, 12th group after a briefing has plunged on depth of 17 m as two subgroups: ahead with the instructor the first pair of less skilled divers, behind them the second pair of more skilled divers. [name removed] was in the second pair. Through 5 mines after the beginning of the dive the instructor has been compelled to lift urgently one pair on a surface and to hand them over to the boat f the diving-centre. Other pair did not ascend as they remained at the bottom. [name removed] went down following the bubbles, however has found only one of the divers which sat in place and did not know where [name removed] went. [name removed] has lifted the diver to the surface. Simultaneously in 20 m away from them on a surface [name removed] showed up, shouting and hatting and clapping the water with his hand and dissaperad under the water. The instructor descended again on that very place where [name removed] went down, but could not find him. Bubles also could not be seen from the diving boat. All dives in the lake have been canceled and all the instructors who were in the territory of the lake were mobilised for searches. First aid, militia and the Ministry of Emergency Measures have been informed. Searches by forces of instructors and a search brigade of the Ministry of Emergency Measures were conducted before dark. In the morning on July, 13th regular instructors of group RuDIVE have been mobilised, but till now searches are ineffectual: Andrey Sovinsky is still mising.
He was diving in a dry suit Northland, Black Diamond BCD and using Legend regulator - all equipment new and his own.
Based on the [instructors] report which is enclosed below, his actions in the given stressful situation are possible to qualify as correct.
According to reports of the instructor and witnesses, [name removed] after has dispersed from group and the partner, did not ascend to the surface after 1 minute, and has gone downhill. Then, after swimming underwater for about 20met he came up to the surface but could not keep positive buoyancy: probably, because of no air in a cylinder and stress, therefore he could not dump his weights from his BCD and orally inflate his BCD.
The diving community grieves over this tragedy and deeply feels for the family of a missing diver who were ashore of the lake when the tragedy took place and the search was initiated. All dives in the lake have been cancelled until full finding-out of the reasons and circumstances of incident. Searches for the missing diver will proceed.
The entire account of instructor [name removed] about emergency 12.07.2009
I, [Instructor], 11.07.2009 in the dive -centre «Spas – Kamenka» was teaching AOWD course for 4 persons. At our acquaintance we have carried out necessary, standard procedures: filling of forms of clearing within admissible risk, the medical questionnaire, checking of certificates.
The first dive took part under РРВ guidances. At 11-30 we have entered into water. Depth of our dive was 15 metres, visibility of 3 metres, a water temperature of 10 degrees, a thermocline at 8 metres.
The group has been put into two pairs. In the first one were the husband with the wife [names removed], the second pair were two men [names removed]. Dive went on perfectly. I have seen level of preparation of each of divers. In both pairs were one diver with excellent possession of skills of immersing. During and after the dive all of them felt perfectly, reaction to the dive – adequate. Under water time was 20 minutes.
The second dive on navigation skills took part the same day (entering water at 1500hrs). Depth of 8 metres, the same conditions. Each of divers has shown excellent skills with a compass. All have returned to a point of enterance. Divetime was 30 minutes.
Last dive of this day was at night. Dive started at 22-00. Students have perfectly proved to be in mastering of technics of giving of signals by a torch, and adequately reacted to surrounding conditions. None of them showed any signes of stress. Bottom time was 20 minutes. After the first day for myself I have made my impressions about each of students.
In the first pair where there was a husband and wife, I saw that [name removed] can have problems in the psychological plan. On the other side, [name removed] behaved very confidently and easy. In the second pair I could not see any problems, but different experience in diving could be seen as [name removed] beng more experienced. As I have found out, [name removed] had a wide experience of diving in the Navy before turning it into a hobby.
Before each dive and after it briefings were held on which we talked not about what we will do, but also about the safety rules (in particular, «a rule of 1 minute» at partner loss under water and necessity to watch air in a cylinder).
12.07.2009 at 1130hrs we have gathered for the fourth dive. We did a briefing, decided about the entering point, direction, conditions, have repeated signals, safety rules. The plan was as follows – we enter from a boat in a deep part, we plunge on a bottom and we swim towards the shore. As in the given group [name removed] was the weakest in preparation level, I have defined that pair [name removed] and [name removed] go a bit ahead, I go near to themt, and a bit behind, in a zone of reach, [names removed]
We were called out by a boat to take us to the entering point. Before the dive, all were defined with a direction, have checked up on a compass, and we have entered the water. Having fallen on a bottom, we have checked up the depth. It was 17 metres, all have looked at compasses, were defined in what direction to go, and the group has begun movement. As I went a bit ahead of the second pair it was necessary to turn around constantly to monitor the second pair. They were confidently swimming behind.
After about 5 min one of [name removed] fins slipped off and she begun to stress and then started to panic. As a result [name removed] loses a regulator that in turn leads to evem more to stress. Apparently, she had a breath of water, but I have reacted and have immediately inserted a regulator back into a mouth then has begun lifting on a surface. At the moment of ascent it seemed to me she does not breathe. Before an exit on a surface normal breathing was restored.
Having risen on a surface, the signal about the help has been given, and the boat at once has approached to us. I have transferred pair to a boat, and went back under the water, whenre there were bubbles approximately in 2х metres from us.
Having reached to the bottom, I have found [name removed] but without his buddy. On my signes where is his partner, he shrugged shoulders, and I have noticed that [name removed] was under stress. Sign was shown “we ascend ". No reaction followed. My actions: took him for a strap of his BCD and dragged him upwards. On a surface we were waited already by a boat. My first question: where else are the bubble? No one saw any other bubbles on the surface, but they saw that as soon as Andrey has jumped out to the surface he slammed hit hand the the water and disappeared under water right away. I went there instantly tot hat place which was about 20 met from where I have just ascended in an opposite side from the shore, I went straight to the bottom. Having reached a bottom, I begun search for the diver, but did not seen anybody. After about 7 minutes I have ascended to the surface. Instructors of dive-centre "Spas-Kamenka«, already with their kit on, ready to begin the search. I together with them continued searches until the full dark. A bit later the brigade of the Ministry of Emergency Measures has joined searches. Unfortunately, search has not brought any results.
The the shore, after a talk with [name removed], I can assume how it all happened. Having entered the water, [names removed], according to our dive plan, were in the second pair after me, holding each other hands. At some instant [name removed] let [name removed] hand go, to show that he has 100 bars in the tank. During this moment myself and [name removed] began to lift [name removed] to the surface, strenuously finning. From this a silt from a bottom has risen, and visibility has fallen practically to zero. [name removed], due to his inexperience, froze in place, without daring to do something. That was the same place I have found him after I went back for the second pair. [name removed], deciding that he has anough experience in diving, has decided to go independently towards the shore instead to ascend to the surface (“a rule of 1 minute” what was constantly told). He went to the opposite side from the shore. His kit was a dry suit, a BCD with integrated weight pockets, a regulator – all new, his own equipment. Probably, he wanted toget to the shore faster and was finning very hard. As a result he used all of his air fast.. Most likely, when air ended, Andrey has ascended to the surface. Probably, because of stress he could not dump weight pockets or inflate orally and the air in his drysuit was ventiladet during the ascend.
13.07.2009
[Instructor]
We were diving near then, DI took the lady underwater with 2 different fins of 2 different models saying to her that it is OK to to that, no matter that one fin could not be adjusted properly.
The name of the DI WAS was published publicly.
On the police report, on 3 various webboards.
StreetDoctor
Not reason to freak out for you or for me or anybody else with gazillion of ice or cave dives but russian instructors in general are pushing the limits in order to make and extra buck, aside of some agency offices selling instructors licences like russian IANTD office does, certifying cave instructors who teach full cave in the pool or teaching divers its ok to get in the water with 4 cilinder with 50 bar in each of thes coz the total pressure is 2000bar which is just enought for diving. then when they kill someon during the course - not their fault.
People TRUST their instructors andinstructors don't care about that.
Tigerman
yeah, they are bad divers in general because they have been taught to act that way, coz their instructors teach them how to qualize, how to go down and up and how to use diving computer. and thats it.
mts0628
that means - last sunday
wilde100
proper translations:
Past Sunday, on July, 12th, in Spas-kamenskii lake [name removed], diving in a group of 4 divers under the direction of freelance instructor [name and # removed]within the limits of course AOWD went missing under water. All the previous day, on July, 11th, the group in the same structure has made 3 dives with [name removed] to depth of 17 m. On July, 12th group after a briefing has plunged on depth of 17 m as two subgroups: ahead with the instructor the first pair of less skilled divers, behind them the second pair of more skilled divers. [name removed] was in the second pair. Through 5 mines after the beginning of the dive the instructor has been compelled to lift urgently one pair on a surface and to hand them over to the boat f the diving-centre. Other pair did not ascend as they remained at the bottom. [name removed] went down following the bubbles, however has found only one of the divers which sat in place and did not know where [name removed] went. [name removed] has lifted the diver to the surface. Simultaneously in 20 m away from them on a surface [name removed] showed up, shouting and hatting and clapping the water with his hand and dissaperad under the water. The instructor descended again on that very place where [name removed] went down, but could not find him. Bubles also could not be seen from the diving boat. All dives in the lake have been canceled and all the instructors who were in the territory of the lake were mobilised for searches. First aid, militia and the Ministry of Emergency Measures have been informed. Searches by forces of instructors and a search brigade of the Ministry of Emergency Measures were conducted before dark. In the morning on July, 13th regular instructors of group RuDIVE have been mobilised, but till now searches are ineffectual: Andrey Sovinsky is still mising.
He was diving in a dry suit Northland, Black Diamond BCD and using Legend regulator - all equipment new and his own.
Based on the [instructors] report which is enclosed below, his actions in the given stressful situation are possible to qualify as correct.
According to reports of the instructor and witnesses, [name removed] after has dispersed from group and the partner, did not ascend to the surface after 1 minute, and has gone downhill. Then, after swimming underwater for about 20met he came up to the surface but could not keep positive buoyancy: probably, because of no air in a cylinder and stress, therefore he could not dump his weights from his BCD and orally inflate his BCD.
The diving community grieves over this tragedy and deeply feels for the family of a missing diver who were ashore of the lake when the tragedy took place and the search was initiated. All dives in the lake have been cancelled until full finding-out of the reasons and circumstances of incident. Searches for the missing diver will proceed.
The entire account of instructor [name removed] about emergency 12.07.2009
I, [Instructor], 11.07.2009 in the dive -centre «Spas – Kamenka» was teaching AOWD course for 4 persons. At our acquaintance we have carried out necessary, standard procedures: filling of forms of clearing within admissible risk, the medical questionnaire, checking of certificates.
The first dive took part under РРВ guidances. At 11-30 we have entered into water. Depth of our dive was 15 metres, visibility of 3 metres, a water temperature of 10 degrees, a thermocline at 8 metres.
The group has been put into two pairs. In the first one were the husband with the wife [names removed], the second pair were two men [names removed]. Dive went on perfectly. I have seen level of preparation of each of divers. In both pairs were one diver with excellent possession of skills of immersing. During and after the dive all of them felt perfectly, reaction to the dive – adequate. Under water time was 20 minutes.
The second dive on navigation skills took part the same day (entering water at 1500hrs). Depth of 8 metres, the same conditions. Each of divers has shown excellent skills with a compass. All have returned to a point of enterance. Divetime was 30 minutes.
Last dive of this day was at night. Dive started at 22-00. Students have perfectly proved to be in mastering of technics of giving of signals by a torch, and adequately reacted to surrounding conditions. None of them showed any signes of stress. Bottom time was 20 minutes. After the first day for myself I have made my impressions about each of students.
In the first pair where there was a husband and wife, I saw that [name removed] can have problems in the psychological plan. On the other side, [name removed] behaved very confidently and easy. In the second pair I could not see any problems, but different experience in diving could be seen as [name removed] beng more experienced. As I have found out, [name removed] had a wide experience of diving in the Navy before turning it into a hobby.
Before each dive and after it briefings were held on which we talked not about what we will do, but also about the safety rules (in particular, «a rule of 1 minute» at partner loss under water and necessity to watch air in a cylinder).
12.07.2009 at 1130hrs we have gathered for the fourth dive. We did a briefing, decided about the entering point, direction, conditions, have repeated signals, safety rules. The plan was as follows – we enter from a boat in a deep part, we plunge on a bottom and we swim towards the shore. As in the given group [name removed] was the weakest in preparation level, I have defined that pair [name removed] and [name removed] go a bit ahead, I go near to themt, and a bit behind, in a zone of reach, [names removed]
We were called out by a boat to take us to the entering point. Before the dive, all were defined with a direction, have checked up on a compass, and we have entered the water. Having fallen on a bottom, we have checked up the depth. It was 17 metres, all have looked at compasses, were defined in what direction to go, and the group has begun movement. As I went a bit ahead of the second pair it was necessary to turn around constantly to monitor the second pair. They were confidently swimming behind.
After about 5 min one of [name removed] fins slipped off and she begun to stress and then started to panic. As a result [name removed] loses a regulator that in turn leads to evem more to stress. Apparently, she had a breath of water, but I have reacted and have immediately inserted a regulator back into a mouth then has begun lifting on a surface. At the moment of ascent it seemed to me she does not breathe. Before an exit on a surface normal breathing was restored.
Having risen on a surface, the signal about the help has been given, and the boat at once has approached to us. I have transferred pair to a boat, and went back under the water, whenre there were bubbles approximately in 2х metres from us.
Having reached to the bottom, I have found [name removed] but without his buddy. On my signes where is his partner, he shrugged shoulders, and I have noticed that [name removed] was under stress. Sign was shown “we ascend ". No reaction followed. My actions: took him for a strap of his BCD and dragged him upwards. On a surface we were waited already by a boat. My first question: where else are the bubble? No one saw any other bubbles on the surface, but they saw that as soon as Andrey has jumped out to the surface he slammed hit hand the the water and disappeared under water right away. I went there instantly tot hat place which was about 20 met from where I have just ascended in an opposite side from the shore, I went straight to the bottom. Having reached a bottom, I begun search for the diver, but did not seen anybody. After about 7 minutes I have ascended to the surface. Instructors of dive-centre "Spas-Kamenka«, already with their kit on, ready to begin the search. I together with them continued searches until the full dark. A bit later the brigade of the Ministry of Emergency Measures has joined searches. Unfortunately, search has not brought any results.
The the shore, after a talk with [name removed], I can assume how it all happened. Having entered the water, [names removed], according to our dive plan, were in the second pair after me, holding each other hands. At some instant [name removed] let [name removed] hand go, to show that he has 100 bars in the tank. During this moment myself and [name removed] began to lift [name removed] to the surface, strenuously finning. From this a silt from a bottom has risen, and visibility has fallen practically to zero. [name removed], due to his inexperience, froze in place, without daring to do something. That was the same place I have found him after I went back for the second pair. [name removed], deciding that he has anough experience in diving, has decided to go independently towards the shore instead to ascend to the surface (“a rule of 1 minute” what was constantly told). He went to the opposite side from the shore. His kit was a dry suit, a BCD with integrated weight pockets, a regulator – all new, his own equipment. Probably, he wanted toget to the shore faster and was finning very hard. As a result he used all of his air fast.. Most likely, when air ended, Andrey has ascended to the surface. Probably, because of stress he could not dump weight pockets or inflate orally and the air in his drysuit was ventiladet during the ascend.
13.07.2009
[Instructor]
We were diving near then, DI took the lady underwater with 2 different fins of 2 different models saying to her that it is OK to to that, no matter that one fin could not be adjusted properly.
Last edited by a moderator:
Spiderpig,
How to you come to be in possession of the report made by the dive instructor? Are there no privacy laws in Russia? In most countries this information is confidential and should only be in possession of the instructor, the police and PADI.
R..
How to you come to be in possession of the report made by the dive instructor? Are there no privacy laws in Russia? In most countries this information is confidential and should only be in possession of the instructor, the police and PADI.
R..
All, let's try not to be so hard on Spiderpig. How he got the report is irrelevant to the discussion of dive safety IMHO. Unless there are questions of it authenticity.
Assuming the report was accurate and true by and large, I reiterate my earlier point that I don't observe any blame to be laid on the instructor at this point, unless new evidence becomes available.
According to the report (unverified), the victim initiated the separation from his dive buddy; attempted to swim back unassisted. I take point here since the report mentions a dive boat, I infer that the distance back to shore was a challenge to swim back to.
There is still not clear evidence the DI was negligent in his duties or could have saved the victim had he not been attending to the first emergency. It is unclear if the victim drowned, suffered a heart attack, etc etc.
Assuming the report was accurate and true by and large, I reiterate my earlier point that I don't observe any blame to be laid on the instructor at this point, unless new evidence becomes available.
According to the report (unverified), the victim initiated the separation from his dive buddy; attempted to swim back unassisted. I take point here since the report mentions a dive boat, I infer that the distance back to shore was a challenge to swim back to.
There is still not clear evidence the DI was negligent in his duties or could have saved the victim had he not been attending to the first emergency. It is unclear if the victim drowned, suffered a heart attack, etc etc.
I think it is relevant.
He seems very keen to assign blame for this incident on the instructor and is making claims, supported by what would appear to be official documentation, about it. I personally question his motives and I wonder how he came to be in possession of this documentation. In most countries, as I said above, there are privacy laws protecting people from having this sort of information becoming public domain before any kind of criminal investigation has been conducted and/or any charges of any kind have been brought to bear.
In short, I don't believe it is the roll of mr. Pig or anyone here on scubaboard to be judge, jury and executioner of this instructor before any kind of investigation by the appropriate authorities has been conducted.
I decided to join this thread and hand off moderating it to someone else so this point can be clearly made. Mr. Pig has a strong need to name the instructor and is unable to understand taht this is not the time. (my PM exchange with him convinced me of this), He is sure that the instructor is to blame and he wants to convince the whole world of the instructor's guilt.
In short. Something about this does not compute. Maybe we're seeing some kind of cultural difference in how these kinds of incidents are "discussed" but regardless of the reasons, I feel that the instructors name should not be made public until someone charges him with a crime and I find it hard to believe that someone who would have access to this information would go public with it this prematurely without having some kind of ulterior motive.
Of equal concern to me is the fact that the names of the victims have also been made public. Generally speaking, if someone is involved in a traumatic accident it is not helpful to them, to their possible legal case and to their families to have their names plastered all over the internet. Once again, we could be seeing something cultural here but I believe that the victims have rights to privacy too and I strongly object to us naming the victims without their express consent. Mr. Pig expressed to me in a PM that he may have 'consent' by saying that "the families want this investigated" which indicated to me that his connection to this incident may be more involved than meets the eye.
Either way, and any way, this line of discussion shouldn't be allowed to continue as long as we fail to act as responsible adults and give the people involved the privacy they should be given. Suppose *you* were the instructor, wilde100. Would you want people to "killing you publicly" on a BBS forum before anything had even been invesigated?
R..
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I respectfully disagree here. Not naming the parties involved should not mean not discussing the incident. If you are going to suggest that the discussion take place after the investigation is completed, it precludes on going "discussions" that already are taking place. The other RU forum is already discussing this - ie names are public. Why shouldn't we, except to be very careful not to draw unfounded assumptions and unsubstantiated conclusions.
Next, I haven't yet begun to massacre the DI. The discussion is to try to understand how to improve safety, which I assumed was the purpose of this board. Rewinding, my responses to this thread begun as a rebuttal to allegations made by Spiderpig.
If the issue is about naming, I will be happy to re-name the parties as Homer Simpson, marge Simpson, or bart simpson, whichever suits anyone. But as apparent, the information is already public (on another board).
Why should spiderpig's vocal cries matter more than the information presented about the case? Let's not focus on the person but the case presented. I have not started this thread to flame anyone, I have made my point that I don't see any fault from the DI yet.
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I went back to the special rules thread to re-read if I misunderstood anything.
Rule1 did mention not to post names, except until after they have become public. Which they have. It does not mention not mentioning names until after the investigation is completed.
The motivation in discussing these incidents at the earliest possible time allows divers to act more safely than waiting weeks for a full accident report to become available publicly.
I have not made these posts with malicious intent (quite the opposite), but stand ready to be questioned and corrected.
I'll say this again, do not let spiderpig's opinions dominate the discussion. Focus on the incident and learning points (with some reasonable assumptions).
Rule1 did mention not to post names, except until after they have become public. Which they have. It does not mention not mentioning names until after the investigation is completed.
The motivation in discussing these incidents at the earliest possible time allows divers to act more safely than waiting weeks for a full accident report to become available publicly.
I have not made these posts with malicious intent (quite the opposite), but stand ready to be questioned and corrected.
I'll say this again, do not let spiderpig's opinions dominate the discussion. Focus on the incident and learning points (with some reasonable assumptions).
Ok, to be clear, I'm not accusing you of anything. I also don't want this discussion not to be held. Maybe there is something to be learned by it. I am, however, trying to state that I believe it's and infringement on the privacy of the people involved to name them like this.
I'm still not sure that they have been named by other sources. You mentioned a newspaper article but up to now the only sources being cited on this thread are from a Russian diving forum and I'm not inclined to take that as an "offical" report, journalistic or otherwise, of anything. The OP did PM me to claim both the police reports and some report from the military were public domain but he did not cite/link/provide this for verification.
I'll remind you of the special rules for this forum:
(1) You may not release any names here, until after the names have appeared in the public domain (articles, news reports, sherrif's report etc.) The releasing report must be cited. Until such public release, the only name you may use in this forum is your own.
We're totally derailed on this point
(2) No flaming, name calling or otherwise attacking other posters. You may attack ideas; you may not attack people.
(3) No trolling; no blamestorming. Mishap analysis does not lay blame, it finds causes.
The OP came out shooting in teh first post was was squarely laying blame before any "discussion" took place
(4) No "condolences to the family" here
(5) If you are presenting information from a source other than your own eyes and ears, cite the source.
The Russian diving forum has been linked but the sources *they* use for this information has not been provided. This is the reason I asked Mr. Pig to cite his sources a couple of posts ago.
(6) If your post is your hypothesis, theory, or a "possible scenario," identify it as such.
Once again, the OP started in the first post to say that the deceased diver died of a heart attack before the body had even been recovered....
So if we want to get back on topic, what do we know:
Taking the report of the instructor and assuming that it's not falsified then we can say for sure:
- This group had done 3 dives together in these conditions and all divers had performed adquately according to the judgement of the instructor.
- Visibility was about 3 metres depth was about 17 metres.
- It sounds to me like there was one instructor in the water and that they were swimming in a "2 - I - 2" formation.
- An incident with a flipper took place and the diver did not respond adquately to the problem and panicked.
- The instructor intervened and took the panicking student to the surface leaving 2 divers behind on the bottom.
- The two divers left on the bottom did not follow the briefed protocol and also became separated during the time the instructor surfaced with the other buddy pair
- The instructor returned to the bottom and rescued one of the members of the other buddy pair but was unable to locate both of them
- There is some speculation in the instructor's report about what happened to the deceased diver after the buddy separation. The only thing that is clear is that people onboard the boat saw him reach the surface alive sink again after splashing a bit on the surface and he is now dead.
In terms of supervision, It's my personal conviction that an instructor should always have another safety diver in the water with groups larger than 2 people, even in ideal circumstances. Standards do not require it, but common sense suggests this is a best practice. In this case, having a DM in the water may have allowed for the "abandoned" buddy team to ascend in a controlled fashion and to have not become separated. There is no guarantee that a DM would have avoided the outcome but I believe their chances would have been improved if the instructor had had backup.
R..
Taking the report of the instructor and assuming that it's not falsified then we can say for sure:
- This group had done 3 dives together in these conditions and all divers had performed adquately according to the judgement of the instructor.
- Visibility was about 3 metres depth was about 17 metres.
- It sounds to me like there was one instructor in the water and that they were swimming in a "2 - I - 2" formation.
- An incident with a flipper took place and the diver did not respond adquately to the problem and panicked.
- The instructor intervened and took the panicking student to the surface leaving 2 divers behind on the bottom.
- The two divers left on the bottom did not follow the briefed protocol and also became separated during the time the instructor surfaced with the other buddy pair
- The instructor returned to the bottom and rescued one of the members of the other buddy pair but was unable to locate both of them
- There is some speculation in the instructor's report about what happened to the deceased diver after the buddy separation. The only thing that is clear is that people onboard the boat saw him reach the surface alive sink again after splashing a bit on the surface and he is now dead.
In terms of supervision, It's my personal conviction that an instructor should always have another safety diver in the water with groups larger than 2 people, even in ideal circumstances. Standards do not require it, but common sense suggests this is a best practice. In this case, having a DM in the water may have allowed for the "abandoned" buddy team to ascend in a controlled fashion and to have not become separated. There is no guarantee that a DM would have avoided the outcome but I believe their chances would have been improved if the instructor had had backup.
R..
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