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Three dead in Poland last week

Discussion in 'Accidents and Incidents' started by Ryszard R, May 24, 2020.

  1. John the Pom

    John the Pom Nassau Grouper

    # of Dives: 500 - 999
    Location: Sydney, Australia
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    I agree. I've only had to do it once in my life, in relatively benign conditions, from around 25m / 80', O/C, no concerns about decompression. She was on the very edge of full-blown panic, overweighted, and finning wildly and sinking. Her buddy was just staring at her - no idea what to do. If we hadn't stumbled upon them and seen that she was in trouble, I suspect she would have drowned. When I grabbed hold of her, she became completely passive. I was able to keep a vice-like grip on her, and plenty of eye-contact, while I swam her all the way to the surface, and thankfully I didn't have to juggle a lot of dump valves. I didn't let go of her until we were safely back on the boat. Even though it was a fairly simple rescue, I was very far from calm, rational, and collected! It still gives me chills to think about all the things that might have gone wrong. It's one thing to do it as a drill in class, but to do it for real was very hard.
     
    Bob DBF, Hoyden, Hiszpan and 6 others like this.
  2. fsardone

    fsardone Solo Diver ScubaBoard Supporter

    # of Dives: I just don't log dives
    Location: Rome, Italy
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    Once again, how much is too much? Commenting in hindsight is easy. The reason we do it is understand the failure point and prevent them next time we go diving. So how many of us will go in low visibility cold lake with a buddy and try to manage their buddy ascent? Please if you do, do it without a deco load. This is training. No need for an instructor. Pretend your friend is incapacitated. If things go sour, he will be able to take over. If visibility is low all the better.

    As stuartv says. Wing, dry suit and counterlung expanding. Times two. Lights. Only two hands. Need to vent at least 2 thing on each diver at any one time requiring hand movement (the wing and the dry suit, while you can vent the loop from the nose - not the incident diver), with the loop of the incident diver at maximum buoyancy ... he is not breathing from it. The you maybe need to have a look at depth gauge and your deco status and maybe ppO2 (not knowing ppO2 will kill you).

    It becomes kind of busy. This is why on serious dives, team of three is better: one shoots the DMSB one helps and the other is the trouble diver, still you have no guarantee that separation will not occur. (BTW what is serious for me of for you?) Establishing buoyancy control is main issue, in CCR ascent (I fully support: it is the most complex, task loading and risky part of CCR diving) having a good depth reference is vital. My instructors, they dive at level I cannot even imagine to match, both told me in case of emergency establish a line (from the wreck or to the bag) and if anchored at the bottom, stay slightly positive, in case to the surface, stay slightly negative and monitor the line to see if is becoming slack or too tight and manage buoyancy accordingly.

    Well, while I can agree you cannot fix dead, I have to highlight that diving He (like 18/50) and coming up from, let's say, 60mt 30min dive, unless the doctor is there with a chamber, you would be quite dead before even be out of the water. If you do the Polaris missile ascent, you will be dead no matter what. So, as everything goes, it depends.

    I would say that, as planning goes, a bit of risk management and analysis would possibly have improved to outcome. And that is planning. So I do not agree with well planned. Also gas was wron, deciding to do a deep dive with no recent experience was wrong, doing it in challenging (maybe not for them?) environment was wrong.

    I did now attach an xls version of the risk management matrix (which can be changed) and a pdf for those who do not have excel. Look at the risk in there, maybe adapt it to your diving and just think about it before going to the dive site. Reassess if condition change.

    I can agree but if you start saying:
    Buddy (vs 3 some) diving;
    Low Viz
    No recent experience
    Deco Dive
    Cold water
    Narking gas
    No DMSB (maybe, not known)
    Unfamiliar equipment

    Then bad decision .... that probably would have been better. But once again, nobody goes to the dive site to die. Why all of the above made sense at the time the decision was made? Can we guarantee that we will not make the same fatal judgemental error?

    Just my reflections on this to contribute to the learning process.
     

    Attached Files:

  3. Dr Simon Mitchell

    Dr Simon Mitchell ScubaBoard Supporter Staff Member ScubaBoard Supporter

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    Hello again,

    It is easy to proclaim something catchy like this and sound wise when judging the event in hindsight with the outcome known, but invoking the stated principle is much more fraught when the event is evolving. Put yourself in the shoes of Diver 1. Up until the separation nothing had happened that gave him cause to think that completing a safe decompression up the slope was an unrealistic goal. At that point charging to or toward the surface and suffering dual cases of (probably) serious DCS almost certainly did not look like the best option. It is easy to say that it might have been in hindsight - maybe (and maybe not because both of them might have ended up bent and dead). But at the time I would have been going for a safe outcome for both divers and would have made the same decision.

    Simon M
     
    Bob DBF, rjack321, vioch and 5 others like this.
  4. Anna G

    Anna G Angel Fish

    # of Dives: 25 - 49
    Location: Toronto
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    I don't think equipment unfamiliarity was an issue; Diver 1 in his write-up said that D2 had been diving this rig for 6 years, and that was was well-maintained.
    Recent experience could be an issue. D2 dove to similar depths about 5 mo ago, and did shallower (20m) dives end Feb/early Mar, and dove in this lake so would be familiar with water temp.
     
  5. fsardone

    fsardone Solo Diver ScubaBoard Supporter

    # of Dives: I just don't log dives
    Location: Rome, Italy
    538
    533
    93
    Agreed,
    I was just thinking of the risk areas:

    Diver
    Equipment
    Environment
    Pressures

    Citing the risk matrix. Recency on the other hand could have played a big role.
     
  6. uwxplorer

    uwxplorer Rebreather Pilot

    # of Dives: 500 - 999
    Location: Los Angeles
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    Hindsight is 20/20. No blame on the buddy, but besides the lessons already drawn, here are a few thoughts.
    The best gas to bailout was not the air in his PSCR cylinders, but his 19/48 stage. He would have had enough to clear up his head and move up to where it would have been wiser to use air (or possibly his 48% bailout/stage). The role of a buddy is to think for his buddy if he/she is functionally impaired. And at this depth on air breathing a unit with unspecified WOB, I would suspect Diver 2 was impaired:
    - I have dived the same 130 ft site on air diluent and 20/20 and while I couldn't remember a thing from the former, I was blown away by the latter.
    - The life of a student was undoubtedly saved when, running out of diluent, she bailout to her rich bailout, which luckily her buddy picked up right away (that was at ~200 ft+, so 60% aren't recommended for too long) and forced her to make the right switch.
    - I have once felt sick in the middle of a dive, and I felt like a baby in his mother's arms while sheepishly following my buddy to the anchor line.
    - etc, etc.
    I think the lesson is that we should not assume that because a buddy gives us the OK sign or doesn't verbalize sheer panic, the brown matter tsunami is not already roaring toward us. We need to think for ourselves and our buddy, and probably accept additional risk to save our buddy's life. Of course, that will not be always (rarely) possible, and not always (rarely) sufficient. But if we are not ready, prepared, trained and assertive, well... those who do not study history are bound to repeat it.
    This report was very useful in this respect (and again, no blame is suggested).
     
    eleniel, Dark Wolf and chillyinCanada like this.
  7. Stoo

    Stoo NAUI Instructor

    # of Dives: 5,000 - ∞
    Location: Freelton & Tobermory, Ontario, Canada
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    You're putting words in my mouth!

    I don't recall suggesting in any way "charging" anywhere, but we all know that any given situation is more easily resolved in shallower water, rather than deeper. And yes, I agree that trying to sort a problem simply at depth is always desirable, but at the point where things start to go sideways, I think heading "upwards" isn't a bad idea.

    You are correct though that the separation of the two ended any ability of Diver 1 to assist in any way.

    My basic "take-away" from this sad scenario is that even a well-planned dive with apparently capable divers can have a catastrophic outcome following some (as of yet) unknown event.
     
  8. mac64

    mac64 ScubaBoard Supporter ScubaBoard Supporter

    # of Dives: 5,000 - ∞
    Location: Ireland
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    What I’d like to know is where rebreathers are concerned does the buddy system work and do you have effective bailout? because in this case neither worked.
     
  9. stuartv

    stuartv Seeking the Light ScubaBoard Supporter

    # of Dives: 200 - 499
    Location: Manassas, VA
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    It seems like most of the CCR divers who have commented are in agreement that the diver actually did not have an appropriate mix of gas in his bail out cylinder. A poor choice of BO gas may have contributed narcosis to a situation where he was already in trouble...

    I'm still very much a newb on CCR, so take my thoughts with a big, fat grain of salt. But, it seems to me that everything about diving a CCR requires staying just a bit further "ahead" than diving OC does.

    On OC, you are always staying ahead of your gas consumption. You look ahead and then plan an ascent to get you out BEFORE you become at risk for running out. You are constantly staying ahead of your breathing, your BCD inflation, and possibly your drysuit inflation. You are starting to inhale before you drop too much. You are putting gas in your BCD before you get to the depth where you want to stop. These are examples of staying "ahead" of the equipment you are diving.

    On CCR, you have to stay further ahead. One example (in my mind - not everyone will necessarily agree, I suppose) is maintaining awareness of the gas you are breathing and your physiological response to it. Staying far enough ahead to recognize the signs and symptoms of an impending CO2 hit, or a hypoxic or hyperoxic event. That can mean realizing you're breathing rate is becoming elevated. It can mean realizing that you feel "wrong". It can also mean seeing a high or low ppO2 # on your computer. Or a red flashing light on your HUD. Whatever. And there are many more things to pay attention to than just the specific things I mentioned. I'm just giving an example to try and illustrate my point.

    Which is that, in my opinion anyway, there is an extent to which a CCR diver HAS to catch things before they progress to the point of incapacitating the diver. Because, as you have alluded, having a buddy be able to "save" you is a much more tricky proposition than having a buddy that can save a diver on OC. Especially if the CCR diver is diving with a normal DSV and not a BOV (Bail-Out Valve). If the diver has a BOV, then there is some chance that his buddy could "save" him by simply flipping the switch/lever on the BOV to switch the diver from breathing on their loop to directly breathing on OC, breathing their bail out gas. With a DSV, getting an incapacitated diver onto known good breathing gas is probably impossible. You'd have to take the DSV out of their mouth and close it and then put an OC reg in. If they are really incapacitated, that is just not happening.

    Regardless, if the diver gets so "behind" that they are no longer able to think or act for themselves, they have already really screwed up - or are very unlucky. Once you get there, it's kind of like driving on a really icy road and now you are already sliding and spinning out of control. If a buddy is able to save you, they have most likely pulled off a MAJOR feat of accomplishment.

    As I said, I'm still very new and these are just my thoughts on it.
     
    mac64 likes this.
  10. johndiver999

    johndiver999 Solo Diver

    # of Dives: 500 - 999
    Location: Gainesville FL
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    No I don't think I made that kind of representation and feel the need to clarify that point. I tried to analyze and understand the situation for my perspective which is ENTIRELY based on OC scuba and went to efforts to emphasize that fact.

    I also have acknowledged that the experts have indicated that grabbing hold of the buddy and coming straight up without any visual or physical guideline was impractical/impossible to do safely. I'm surprised by that conclusion, but do not refute it.
     
    lowwall likes this.

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