Training fatality after Instructor held student down - Stoney Cove, UK

[Bob DBF]

"In short, the defendant's decision to take hold of Mr Stansfield and prevent him from reaching the surface and continuing the procedural stop - despite the fact it was wholly unnecessary - caused Mr Stansfield to become unconscious, to suffer a cardiac arrest."

It is my contention that the heart attack started at depth, or on the ascent, rather than caused by the enforced safety stop. The student's continued insistence that he was out of air and could not breathe, could easily be a symptom of an ongoing cardiac event, rather than an OOA emergency. Considering the communications issues underwater, I could see the confusion, and would have surfaced to clarify what was happening. One can always drop back to the stop, if necessary for training.

 

[Esprise Me]

I may have misunderstood earlier regarding safety stops being "required" by PADI; perhaps it's that they are required in order for a training dive to be considered successful and therefore count toward certification. Is that the case? And if so, can a training dive in which a student runs out of air still count if the student successfully completes the dive on the instructor's octo, with a safety stop?

 

[doctormike]

I have no idea what happened, but if we are interested in learning about an accident and preventing a recurrence, simply reading the prosecutor's statement verbatim might not be the best way of getting an accurate account.

I, of course, agree that someone in serious trouble should be on the surface. However, sometimes instructors (I'm not one) have to deal with panicked divers in training, and getting them breathing from a working air source is sometimes preferable than having them just surface immediately.

Yes, in retrospect, since this diver died, we are all tempted to say that we would have definitely surfaced him since he was clearly dying. All I'm saying is that I doubt that the instructor's thought process was "Huh. Drowning diver. Well, nothing is more important than a safety stop, so we had better do that".

 

[boulderjohn]

I think several people have made excellent points, particularly Bob DBF and doctormike. I would like to compare an incident that happened to me, giving my thinking, and compare it to what I speculate may have happened in this case.

It was a trimix training dive, and the student designated to lead the dive started the descent with no issues, descending as normal next to the line (not touching). At 150 feet, he paused, with an uncertain look on his face, and I went to him because he seemed concerned. He gave the "Something's wrong" signal, and then he grabbed the line and showed the thumb emphatically. I got ahold of his harness and the line and went up with him. He later said he had no memory of the ascent, but he was in control of himself all the way. He vented both his drysuit and wing on his own in order to control the ascent. He continued to grip the line as he went (very unusual), and he was still gripping it on the surface. He said he had suddenly been overwhelmed by vertigo, which we later learned was caused by a tiny perforation in his eardrum.

As we ascended, I noted that he had control of himself. I was also aware that this was a highly experienced diver who knew what he was doing on a normal dive. He had signaled that something was wrong, which clearly indicated to me that he was having a medical event of some kind. The fact that he was gripping the line on ascent told me that something unusual was happening. I therefore trusted his need to get to the surface and assisted that ascent.

When I compare that incident to this one, I see several key differences. First, I do not see that the student gave a "something's wrong" signal, leaving it up to the instructor to draw conclusions from what he was seeing. He was working with an inexperienced diver, and he might have compared him to other inexperienced divers he had had in the past. He had seen many new divers who feel a need to get to the surface without any real need to do so. Such divers will often be wide-eyed and close to panic. He had plenty of air, so there was no need for him to skip the safety stop. If he had let the diver go to the surface after a 100 foot dive with no safety stop, and if the diver had gotten DCS, an attorney would likely be suing him for not having him do the safety stop.

I agree with those who believe the cardiac issues happened well before the safety stop. The diver lacked the experience to know that what was happening was not normal, and he lacked the ability to communicate what was happening--which he probably did not understand anyway. The instructor made the error of attributing the signs of medical distress to the inability of a new diver to appreciate the fact that everything was OK now, and could relax and do the safety stop as recommended.

 

[boulderjohn]

Here is another comparison.

My nephew's mother-in-law was talking an AOW class, and she suddenly panicked and tried to sprint to the surface. The instructor tried to stop her, but she ultimately got free and made the ascent. The cause of death was determined to be an embolism caused by her rapid ascent, but the rapid ascent was the result of her heart attack.

So what do you, the instructor, do in that case?

 

[Seaweed Doc]

Here is another comparison.

My nephew's mother-in-law was talking an AOW class, and she suddenly panicked and tried to sprint to the surface. The instructor tried to stop her, but she ultimately got free and made the ascent. The cause of death was determined to be an embolism caused by her rapid ascent, but the rapid ascent was the result of her heart attack.

So what do you, the instructor, do in that case?

Not sure I quite understand: Heart attack starts, she bolts, then embolizes? Or she starts to bolt, embolizes, triggers heart attack?

As an instructor in this situation I'm trained to stop a bolting diver, at least flaring out to slow their ascent. Given what sounds like a rapid sequence of events I don't think an instructor could be expected to determine exactly what was wrong.

As an instructor, I have also monitored students breathing on such "bolting" ascents as well as simply losing buoyancy control. If there regulator is out I'll grab it and touch it to their lips. One bolter I had figured out that he was better off and put it in his mouth. He had been exhaling on the ascent without it. If they aren't exhaling, I am not trained to punch them in the stomach. I will not claim I've done that with a breath-holder. Further, I'll not claim I've only done this once and it was effective in causing the diver to start exhaling. [[The last sentences modified by my attorney.]] In both these instances, the bolters had done every other skill perfectly. Nothing suggested they'd have an issue on any skill. The breath-holder was in a class setting. Me, 3 students, no DM. I quickly signalled the other students to ascend as I intervened but put the priority on intervention. Both bolters felt sheepish then repeated the skill just fine and finished off their certification.

I've also had students lose buoyancy control and start to float away. I try to intervene if there's any risk to the student. I'll also intervene if I think I can stop them from rising too far, especially if I have a group down. I'll intervene if it's 1 on 1 instruction. But if their safety looks good (they're not breathholding), we're shallow (say 20' or 15'), I'm not going to be able to stop them surfacing, and I have other students with me at depth, I might let them go. I'll signal the rest of the group to ascend and make sure they all begin safe ascents together. My priority shifts to the group. (This modifies with a DM: I'd send the DM to the surface immediately with the ascending diver.)

Happy to have other instructors critique this approach. I'm humble enough to modify my technique if there's a better way.

 

[Seaweed Doc]

My thought on the OP was as others have said: I wonder if he started having cardiac issues at depth and that triggered the difficulty breathing.

To play Devil's advocate for a moment (keeping in mind the story is only the prosecutors' side):

Coming up from a 100' (30 m, as reported) dive that safety stop is less than a trivial item. No, not "required" but more important than a standard safety stop. Discussion above establishes that.

I think this was a "Deep Diver" certification, not the "Deep Dive" of AOW. I haven't looked it up, I think this means you'd have to have a staged bottle at your safety stop. I'm going to ass-u-me that such existed, and was being used. Could be wrong. Either way, there appear to have been plenty of cylinders and spare regs around, given the switching back and forth. A staged bottle is a bit easier for the OOA diver to use than shared-air, IMHO.

I'll take the instructor at his word that he only grabbed the diver once and signalled to stay down, he didn't physically restrain him. (There were other divers on site who can corroborate or contradict this in court; the fact should be easy to establish.)

The only issue the diver indicated was wrong was that he was out of air (twice). There's no indication he gave a thumbs up to request ending the dive, or indicated a cardiac event. (He likely wouldn't have known. But then neither would the instructor.) He did attempt to ascend.

The way I read the story, I think he asked the diver to stay at depth and the diver complied. That could be construed as "holding" the diver at depth. Like a police officer controlling an intersection might "hold" traffic going one direction while cross-traffic proceeds.


Now taking off the defense attorney's hat, here's where I think the instructor erred for sure:

He had an apparently out of air diver. As in totally out, no air in his main tank or any ponies, backups, etc. that diver had on their person. Training at that point suggests the diver and his buddy should ascend to 15', hold the safety stop if air remaining allows, then ascend to the surface. Continuing the dive shouldn't be done.

OK, so let's say he continues the dive anyway. Somewhere in this process, especially after a second OOA, I'd have checked the pressure gauge. Is the tank empty, or is it a reg problem, or user error? TBH, even if a student indicates low on air I'll still visually check the gauge. Especially at a safety stop where you've got time and a whole lot of nuttin' to do. I'm really curious if the diver was in fact out of air or just had trouble breathing.

The prosecutor states the victims' eyes were "dilated." That's odd wording, at least to my North American ears. Were the eyes wide open (which I think this literally means, but is something I wouldn't say) or were the PUPILS dilated? This matters: If I see dilated pupils, I presume medical emergency and we ascend. Not sure I'd notice it in a masked face underwater, but if I did it's dive over now and emergency rescue protocols kick in. If it was "eyes wide open" I'd have signalled the diver to calm down and breathe deeply. I'd be paying attention to breathing pattern to see if they were breathing rapidly and shallowly. At that point, I'd be hyper-focused on the diver and asking if they were OK. If they say no, it's dive over.

Then there's the "regulator slipped from his mouth" several times, pretty much as he passed out. Besides making me more convinced a medical event was already in process, this is one red flag too many. I'm going to assume the diver really was passing out. There should have been other signs, like lethargic recovery of the reg or a change in how arms are held. If so, again, rescue protocols should kick in.
Lastly, a line I use with all student divers (and not my own creation): Better bent on the surface than dead underwater.

I really would like to hear from the DM on this. What was their perspective on how things were handled?

 

[Seaweed Doc]

OK, already posted too much but I'll add a couple of related stories. I've never had a student diver out of air during a dive. I'd like to think that's because of my brilliant instruction, but there have been 4 students so low on air that I'd have to admit some imperfection on my letting them get that close. The 4 students were on two different training dives, so 2 students per dive.


Case #1: We were doing the "Deep" dive of AOW. I've never had a student come close to OOA on this one, though any exploring beyond just doing the required skills has often not happened due to one student being low on air. As usual for me, the divers descended to 100'/30 m. The descent was a bit slower than usual, as one student had difficulties clearing her ears. On the ascent, I knew one diver was lowish on air so we headed straight to a staged bottle placed at close to safety stop depth. It was on the bottom in a spot where landmarks made it easy to find. When we got there, I realized I had 2 divers low on air. I decided to have them do the safety stop, but breathe off the spare tank. I wanted to reserve the air in their tanks for the ascent and inflating their BCD's on the surface. Things went fine: They were just heavy breathers.

This differs from the OP for several reasons: They were not out of air, just low. They showed no signs of distress and swapped regs with ease. They both ended up fine and learned they needed to invest in 100 cf tanks.

But this could have gone sideways: A staged bottle isn't required for the Deep dive in AOW. (It would be for Deep Diver certification, though. If I recall correctly.) If one hadn't been there, should I have brought the group up from 15' with no safety stop? Nobody was OOA, but they were close. Maybe have them alternate breathing off my secondary while at the safety stop? Not sure what I'd have done.

Case #2: OW dive #3. One buddy team (husband/wife) was with me. I had a larger group, but had dispatched the rest with a DM for the "tour" portion of the dive. These two were slower getting in the water, so I had them hold back and I in essence did a second dive just with them. My error on this one was having them demonstrate skills a bit too deep, like at 50', to avoid murk kicked up by my first set of students and other divers in the area. It's allowed, but in fumbling with gear and such they wasted a lot of air. By the time they'd done skills, I knew we needed to head straight up the slope to the beach. No time for a nice tour. By the time we got to the safety stop, one buddy was so low I didn't think they'd be able to hold the stop and have air to inflate the BCD at the surface. So I shared air at the stop, then switched them back to their air for the ascent and swim in.

Again, they were not out of air, just low. They were concerned, but not panicked and readily accepted my solution.

I think in both cases my partial error and the instructor in the OP's case's major error was not much more carefully and frequently checking air supply of the students.

 

[boulderjohn]

Not sure I quite understand: Heart attack starts, she bolts, then embolizes? Or she starts to bolt, embolizes, triggers heart attack?

I am not a doctor, so I don't know how they determine these things. She had apparently had at least one heart attack during the dive. This led to panic and the desire to bolt to the surface. Bolting to the surface created the embolism. She might have survived the heart attack had she not died from the embolism.

 

[Raphus]

If the student Is having a horrible time then isn’t that a reason to skip the safety stop?

Many times people drown despite the availability of a working reg. There was a double fatality off the south coast here where one of them died having given up recovering a slightly failed rebreather while two or three divers were with him offering their bailout In his face.

Try out being in a pool with a load of divers, dumping your kit and finding gas from some distance away so it is a bit difficult. See if you can succeed 100% of the time and never decide surfacing is easier. Loads of working regs, but too hard to use eventually.

Sure if someone is having a bad time then surface. If the diver was calm and had i breathing reg then a safetystop is still advisable in my opinion.

After rereading: he was half unconscious.. so jeah thats not the definition of having a good time. There is no reason to not surface!