Virginian diver dead at 190 feet - Roaring River State Park, Missouri

[PirateFoxy]

Yes, I know what it is. Are you familar with the case I'm talking about?

Yes, I've watched the film as well. The whole point of the film is that all of the factors leading up to the day of the dive resulted in an environment in which it was easy for a simple error or oversight to occur. With diving there are a large number of simple errors and oversights that can have disastrous results, the specific detail of which occurred isn't as relevant as the environment in which people were set up to make those errors/oversights. That's the point - it could just as easily have been something else which he'd forgotten to check properly that ended up killing him, because he was in a situation in which he simply wasn't doing proper checks and didn't feel like he could say his mental state wasn't right for diving/wasn't able to properly assess his mental state for diving, nor did the other divers involved, any of whom could have also thumbed the dive since he wasn't the only one who was having issues - but *none* of them felt like they could say 'no, this is just a bad day today, we shouldn't do it.' It could just as easily have been one of them who made a mistake and died, instead of him. The entire situation was a problem looking for a way to happen because of the human factors stacked up against the divers doing things properly and in the right mental state.

 

[berndo]

... it could just as easily have been something else which he'd forgotten to check properly that ended up killing him, ...

No, not really. All the points talked about in the film were trumped by the instructors behaviour pre dive.

... because of the human factors stacked up against the divers doing things properly and in the right mental state.

No. I don't think the students or whatever happened to them was the issue.
Students get stressed and make mistakes in class, that's normal... usually an instructor is there to make sure you're doing what you're supposed to and corrects you when you got it wrong.

This is OP and doesn't really belong in this thread.

 

[PirateFoxy]

No, not really. All the points talked about in the film were trumped by the instructors behaviour pre dive.


No. I don't think the students or whatever happened to them was the issue.
Students get stressed and make mistakes in class, that's normal... usually an instructor is there to make sure you're doing what you're supposed to and corrects you when you got it wrong.

This is OP and doesn't really belong in this thread.

It was the final dive of the class and they were all experienced divers already, not OW newbies. The divers and their procedures should have been at a place where they didn't *need* the instructor to remind them of basic points of safety. Trying to put it all on the instructor (who was absolutely part of the problem) is ignoring all the other issues going on - including that none of the students felt empowered to call out the instructor for failing to be a decent instructor. If you don't learn that from the film, then IMO you've missed the point entirely. It's not for instructors to be better at their jobs, it's for *all* divers (and anyone else engaged in activities with risk) to be aware of the entire range of things that combine to create an environment in which it's not a question of if a major issue happens, it's a question of when and which one. There are a number of points, highlighted by the film, where a student or a random diver could stop and say 'wait a minute' if they are paying attention and understand the importance of calling things out when they see them, even if it seems a small thing at the time.

And it's relevant to the incident in the OP because there are valid questions to be asked about standard practices and procedures by the team that may have contributed to the diver being able to take the wrong gas with him and use it on the dive. (Did they get lazy about pre-dive checks? Do some members of the team feel intimidated by the experience of other members and so not ask necessary questions or let themselves feel rushed in preparing? Is there a culture of encouraging ANYONE to use a BO tank rather than follow some notion of 'saving it' for other divers? Etc. etc. etc. ) (I am listing questions to be asked, not stating these things did or did not happen.)

 

[berndo]

It was the final dive of the class and they were all experienced divers already, not OW newbies.

Doesn't matter that they weren't OW newbies. They were brand new to ccr. It was a mod1.

The divers and their procedures should have been at a place where they didn't *need* the instructor to remind them of basic points of safety.

A class has a min amount of dives with an instructor for a reason.

Trying to put it all on the instructor (who was absolutely part of the problem) is ignoring all the other issues going on - including that none of the students felt empowered to call out the instructor for failing to be a decent instructor.

As I already said. Students can get stressed out in a class or be nervous or whatever. Students will make mistakes in class. That is normal.
Letting the student jump in the water alone, o2 off, no pre-dive checklist, no pre-breath to ensure the unit is working, without paying any attention to what his student does... during a mod1 class, is not normal. On top of that he lets the student bring a camera. And that's not all on the instructor? wow

It's not really related to topic of this thread.
I don't wanna go through the rest.

 

[formernuke]

Doesn't matter that they weren't OW newbies. They were brand new to ccr. It was a mod1.

A class has a min amount of dives with an instructor for a reason.


As I already said. Students can get stressed out in a class or be nervous or whatever. Students will make mistakes in class. That is normal.
Letting the student jump in the water alone, o2 off, no pre-dive checklist, no pre-breath to ensure the unit is working, without paying any attention to what his student does... during a mod1 class, is not normal. On top of that he lets the student bring a camera. And that's not all on the instructor? wow

It's not really related to topic of this thread.
I don't wanna go through the

I was like WTF was that instructor doing.

It was the final dive of the class and they were all experienced divers already, not OW newbies

Going from OC to CCR is pretty much going back to CW1 of OW, in my experience at least.

But this is largely off topic.

 

[berndo]

I was like WTF was that instructor doing.

Yeah, the story is nuts.

 

[PirateFoxy]

I was like WTF was that instructor doing.



Going from OC to CCR is pretty much going back to CW1 of OW, in my experience at least.

But this is largely off topic.

Experienced OW divers should (in theory) be able to say "I'm going to thumb this dive" to an extent that you wouldn't expect from an absolute newbie, since the entire environment is not new to them. If they can't do that reliably, then that is a human factor that needs to be taken into consideration when planning things - including procedure and protocol for team cave exploration.

I am not saying the instructor was doing the right things, or didn't contribute to the incident. I'm saying it's all those little other things that are being dismissed as "not the real issue" that help create an environment in which something going wrong (like an instructor being incompetent, or someone taking the wrong gas on a dive) can result in a major problem and potentially a fatality instead of being caught before things get to that point. And that's what the film is about, and what should be being examined in a situation like this one - obviously the team needs to tell us exactly nothing, but I'd hope they're reviewing all of their routines and protocols and procedures and revising as needed to make sure they aren't creating more 'holes' in the cheese that might line up some day. That's the appropriate response to an incident, even if you're pretty confident you ARE doing things right - make sure you're correct that your set up is appropriate, make sure people are still doing what they're supposed to be doing, etc.

 

[Aura]

Insisting on finding the one single cause for an accident, while totally dismissing everything that lead up to it and made it an issue in the first place, is an incredibly simple minded and anti-intellectual approach, and it removes the possibility of actually learning anything and improving SOPs in a meaningful way. If your only lesson learned from this is "Don't bring the wrong gas for the wrong depth", then it's not surprising that things like this unfortunately keep happening. Everybody knows that already.

It's exactly the same when people in the Doc Deep thread all of a sudden dismissed the million wrong decisions, poor planning and ignoring red flags that led to that fatal dive, and blame the entire incident on "compression anthralgia" and nothing else. 《Mod Edit》

 

[berndo]

Insisting on finding the one single cause for an accident, while totally dismissing everything that lead up to it and made it an issue in the first place, is an incredibly simple minded and anti-intellectual approach, and it removes the possibility of actually learning anything and improving SOPs in a meaningful way

Nobody insisting on finding a single cause. In some case it's muddying the waters to talk about how some student felt and trying to somehow relate that to the instructors conduct. Also alot of stuff that people call 'hindsight' these days is not hindsight. Trying to push one model onto everthing doens't work all that great.
《Mod Edit》

 

[formernuke]

What have we learned from the roaring river accident or Gus's incident? Is there anything specific?
I'd be genuinely interested in hearing this.
Has anyone drawn some lesson from this?

Bringing and using wrong gasses can prove fatal is the big one.