Suit filed in case of "Girl dead, boy injured at Glacier National Park

[Esprise Me]

Thanks for sharing, @buddhasummer. I'm assuming you were properly weighted when you did this experiment, even if you were negatively buoyant due to not inflating your suit? I'm thinking this girl was probably overweighted by 10-20 pounds, maybe more. Chilling.

I was thinking about this last night, specifically thinking of how the plaintiffs might properly introduce into evidence the importance of a drysuit hose, proper weighting, and ditchable weight, along with proper training to use a drysuit. Presumably they're going to have at least one expert witness on scuba diving and instructional standards. But I bet it would be really effective to recreate the incident, like you did, but perhaps with a girl of Linnea’s approximate size and shape. The girl could testify to her subjective experience as to what the squeeze felt like and how difficult it was to swim, and the safety divers with her could testify as to how difficult it was to rescue her with all that weight. Then a jury could be as horrified as we are. Might give poor Bob some peace, too, to hear how difficult it was for a team of professionals to do what he was unable to do by himself, during his AOW course, while being kicked in the head by his instructor.

 

[boulderjohn]

Good point. Given the weight distribution, I would guess she was extremely leg heavy. So basically vertical. Unless she had her exhaust valve closed, then any air she had at the surface woukd be squeezed out, making it a more shrink wrapped and constricting situation than what I have experienced.

According to the filing, she was originally standing on the bottom, signalling for help, before falling to to deeper level That would have vented all the air from the suit. It actually goes without saying that she was standing for the first part of the dive--with 44 pounds of lead and an insufficient BCD to provide buoyancy, her two choices would have been standing on the bottom or lying on the bottom.

 

[boulderjohn]

I'm pretty sure the plaintiff's legal team is reading and benefitting from the discussion.

The plaintiff's team does not need any help from this thread. The defense, on the other hand, should be learning what kind of strategies will not work in their defense.

 

[Miyaru]

According to the filing, she was originally standing on the bottom, signalling for help, before falling to a deeper level That would have vented all the air from the suit. It actually goes without saying that she was standing for the first part of the dive--with 44 pounds of lead and an insufficient BCD to provide buoyancy, her two choices would have been standing on the bottom or lying on the bottom.

I was assuming the same: deflator/exhaust-valve fully opened at the start of the dive. Considering the lack of instruction I assume she didn't touch the deflator or even knew how it works. The pdf doesn't mention anything about deflation.

Does anyone know what kind of drysuit she had?
A neoprene drysuit is mentioned in (77), (78) mentions rubber or nylon fabric.
The undergarments mentioned in (156) are likely not the insulating suit required when using trilaminate.

 

[Esprise Me]

It was a Brooks drysuit, according to the complaint. Someone--I think @Marie13 ?--stated earlier in the thread that they only make neoprene/crushed neoprene drysuits, though I haven't verified that myself.

 

[sea_ledford]

I'm struggling a lot with this incident. I've taken several of Gareth Locke's human factors classes, and I try to recognize my hindsight bias. I also completely believe that the death of a student was never something that the instructor or dive shop expected to happen.

But... I just can't get over the complete utter lack of common sense, risk analysis, situational awareness, hell even a slight familiarization with standards. With most incidents, breaking a single link in the chain of problems would likely change an outcome. In this situation, there are like 5 things that would have needed to be done differently. It is really just flabbergasting.

Things I understand from a decision making standpoint (Emphasis on understand, not agree with):
-Adding an additional student to an in progress class. Clearly not ideal, but I can see a shop pushing another student into a class, especially if it was potentially the last class of the year. I can also see a shop instructor not feeling empowered to say no to that.

-Combining different classes - same justification as above.

-Conducting a dive too late in the day. I almost did this a couple years ago. There were several extenuating circumstances and I was in "go mode". I was coming up from one deep dive with students and had one more group left, and on the safety stop I was thinking about how I needed to make sure the incoming students had lights, etc. Once I surfaced, the incoming students said they thought starting a deep dive right after sunset was stupid. They were right of course, but we also empower them to make those decisions, and it saved my bacon that day.

-Trying to cobble together some solutions to equipment problems. Specifically, adding weight to the suit pockets.

-Making poor decisions in general while at the dive site, trying to salvage something out of a CF situation.

-Task focusing and missing something happening underwater. I can't count the number of times I've had students swim within 3 feet of me while compassing, and they never knew I was there. Of course those were AOW students, not instructors... but it still happens.

Things I just can't understand WTF they were thinking:
- an "assistant" with only an open water certification - should have never happened, and the decision to do so was apparently made before the class started. It was PLANNED!

- no DS inflator hose AND no way to hook one up. Dive over before it starts. On what f@!#ing planet is that an optional piece of equipment? Especially given the profile of the lake.

-The sheer amount of weight added. Please don't take me saying I understand putting weight in the DS pockets as approval of putting 44 lbs on this poor girl, I'm thinking like 4-6 lbs MAX, and only after doing a weight check, and probably toward the end of a dive when the student was getting floaty. How much weight did the instructor use? Is 44 lbs in the realm of normal for her? Was it added by the student, the instructor AND the openwater "assistant" with none of them communicating? Overweighting I understand, but this is in the cement shoes category.

-The selection of the dive site is one of the things I'm actually struggling with the most. Why this site? Is it the only one around? They had no permit, no means of any sort of communication without a 30 minute drive (who knows how long until help arrived, but it has to be at least an hour), the bottom profile is inappropriate for the class, it was cold as hell, and it's isolated and after season so there are no bystanders around. Again it was PLANNED to be that way! This wasn't a spur of the moment decision, they were in the warmth and safety of the shop when the decision was made.

The commonality of all of the things I don't get are that they are all decisions that were made before even getting in the water. I just don't get how either an instructor or a dive shop would not have the sense of self preservation to make those decisions. That is probably 2 to 3 people that knew most, if not all, of the above and thought "yeah, that should be okay."

WT actual F?

 

[boulderjohn]

Because people are asking questions that were covered in early posts, I thought I would refresh my memory on several issues. In doing so, I decided I would reply to misconceptions that may have developed.

I would like to begin with a portion of the legal filing that says that in order to teach the AOW Adventure Dive for drysuit, the instructor must follow the Drysuit Specialty course. I am not sure what that means--you certainly do not have to do the full specialty course. Sine all AOW adventure dives can be used as the first dive of a specialty class, I assume that is what they mean.

Here are the PADI requirements for the AOW drysuit adventure dive:

Dry Suit Adventure Dive
Considerations
1. Directly supervise divers at a maximum ratio of 8:1
or have a certified assistant supervise divers at a
maximum ratio of 4:1.
2. Orient divers to dry suits in confined water before
divers use them for the first time in open water.
3. Each student diver must use a dry suit.

Performance Requirements
1. Put on and remove a dry suit with another diver’s
help.
2. Adjust weighting at the surface – deflate BCD and
dry suit, hold a normal breath and float at eye level
(top of head level if using a rebreather).
3. Perform a controlled descent and avoid suit squeeze.
4. Demonstrate neutral buoyancy by gently rising and
falling in a controlled manner during inhalation and
exhalation for one minute (rise and fall not required if
using a rebreather).
5. Hover using buoyancy control for at least one
minute, without kicking or sculling (minor hand
sculling allowed if using a rebreather).
6. Maintain neutral buoyancy during the dive and
avoid accidentally kicking up silt or touching the
bottom.
7. Perform a neutrally buoyant ascent from the
bottom, at a rate no faster than 18 metres/60 feet
per minute.
8. Make a safety stop at 5 metres/15 feet for at least
three minutes.
9. Remove and replace scuba kit and weights at
the surface.
​

As you can see, almost none of the requirements were completed or even attempted.

 

[Esprise Me]

But... I just can't get over the complete utter lack of common sense, risk analysis, situational awareness, hell even a slight familiarization with standards. With most incidents, breaking a single link in the chain of problems would likely change an outcome. In this situation, there are like 5 things that would have needed to be done differently. It is really just flabbergasting.

I completely agree with your flabbergasted-ness at the huge number of things that were done very, very wrong here. But I still think this tragic chain of events could have been stopped if they just hadn't put her in that non-functional drysuit. She survived an earlier dive with this shop in 2 wetsuits; not saying that was a good idea or that none of the other problems with this whole situation matter, but I think the point at which she entered the water with no suit inflator and 44 lbs. of unditchable lead was the real point of no return here. It breaks my heart.

 

[boulderjohn]

I find part of the filing misleading:

93. The PADI Dry Suit Diver Specialty Course requires “Direct Supervision,” where the Instructor must “Position yourself so that you … can make immediate physical contact with and render assistance to divers” and “Continually observe divers with only the brief, periodic interruptions needed to lead the dive and to provide assistance to individual divers.”
94. The PADI Advanced Open Water course requires only “Indirect Supervision” for dives of less than 60 feet in depth, where the Instructor must “Be present and in control of the activities, but not necessarily directly supervising all activities.”
​

This implies that no direct supervision of students is required for the AOW course, but as the standard quoted in post #457 indicate, for drysuit dives direct supervision from the instructor or certified assistant is required.

There was no direct supervision from anyone, certified or uncertified, on this dive.

 

[rsingler]

And perhaps that's the genesis of this Instructor's error chain. Perhaps she thought that since AOW only requires indirect supervision (I have not confirmed this in my manual, and frankly doubt that is completely true), she could watch the victim out of the corner of her eye while concentrating on the other students? Completely forgetting, of course, that this was the victim's first time in a drysuit.

Playing Devil's Advocate here...