What went wrong here....anything?

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Beachman

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I just returned from a well known liveaboard trip that incurred an incident that I would sincerely like to present to this forum for comments and observations. I certainly have formed some opinions of my own, but will reserve them so as not to influence your inputs.

The dive was described by the divemaster as a drift dive along a reef sloping from 80' to 100', then dropping as a wall to great depths. She cautioned all divers to watch their depth gauges closely. Entry procedure would be to collect on the current line, then it would be disconnected from the boat with about 85'of line which she would use as a down line to lead the dive from that depth. A second cruise employee/diver (not DM certified) would follow the group as a dive "supervisor" (can't think of a better word since they were not a DM). A third cruise employee DM certified would be in a dingy near the float ball watching for any early ascents or problems.

The group of 17 divers, which included an instructor and four DM certs and various levels of experience down to OW with 12 dives, collected on the line as described and descended together upon the DM's signal. At 50' it was obvious to me that the group was dispersing rapidly from each other. I stopped at 95' with the dive leader in sight and about 70' viz, located my buddy about 50' away, and noted 8 or 10 other divers in sight. As I atttempted to drop to about 110' where I would be on the edge of the wall, I noted with interest that I really had to goose my BC to keep from dropping uncontrolably over the edge of the wall, but nothing more. I also noted bubbles rising from below me in the distance over the edge of the wall, but had heard a couple of the very experienced folks talking earlier on the boat about doing the dive as deep as 150' for a while.

When the DM sgnals the end of the dive and we surface to circle for pick-up on the float line, it's obvious our group is smaller (by 5 persons it turned out). Apparently there was a difficult down current which not only dispersed the group at entry, but swept many over the edge and down the wall. One diver had dropped their belt at 150' to stop her descent, became overly buoyant at about 100', surfaced like a balloon, and was picked up by the dingy frothing at the mouth with blood also running from her mouth and nose. She had no assigned buddy. Another buddy team separated in the down current. One surfaced after being swept down to 160' (reasonably controlled, I assume). Her buddy was found by one of the DM cert divers clinging to the wall at 160' totally narced. The DM and his buddy surfaced with the victim and were also picked up by the dingy. His computer later showed that he bottomed out at 200'.

All three divers rescued were evacuted to a deco chamber facility, where it was determined that the frothing/bleeding vicim had also suffered a heart attack (probably initiated by sheer terror and panic from the rapid ascent).

The group was so spread out from the begining of the dive that even in in the 70' viz neither the lead DM or following "supervisor" were aware of any problems until we surfaced. The strength of the down current was verified by several other divers, including the instructor and one DM, who bottomed out at about 140' before gaining contol.

All victims turned out OK. All were given a few hours in the chamber as a precautionary measure and released. The heart attack victim was retained for a heart cath procedure and is doing fine now.

For y'all....Should anything have been done differently? Did the cruise team do things right? Should procedures for the dive be revised in the future? This dive has been conducted many times over many years without incident, and no significant down curents detected previously. Is this just a case of "**** happens"?

Really interested in your observations.......have I left anything of significance out of the facts I've tried to set forth accurately?

 
could you let me know who this cluster f@*% of an operation is, either by posting it here or via e-mail. I know its not nice to point such fingers, but I know that I do not want to take that trip.
 
You ask:
"Should anything have been done differently? Did the cruise team do things right? Should procedures for the dive be revised in the future? This dive has been conducted many times over many years without incident, and no significant down curents detected previously. Is this just a case of "**** happens"?
-----------------
Yes, no, yes, no.
In mishap analysis one must identify the links in the chain that led to the mishap, and the weak links in the plan that broke down.
1. The briefing
Any time you combine the terms "drift dive" and "wall" you must assume upwellings and/or downcurrents will be there - wall+current=upwelling or downcurrent in every case unless the current is flowing precisely parallel to the wall. The possibility of downcurrents and the bailout procedure must be briefed.
As the dive leader planned to lead the dive from 85', 85' without bottom should have been briefed as a "miss" - a miss on the deep side of a wall drop should set off all kinds of alarms in the dive leader's head, and should have been briefed. Think about what causes a miss on the deep side... bad nav or current, but we *must* assume it's current, a current going shallow to deep, a current that will be a downcurrent as it flows over the wall.. hear the alarms going off in your head yet? A level-off at 85' (or some other predetermined intermediate depth, but certainly above 100') should have been briefed, and a swim back to the reef at that depth to start the dive on the wall. Whenever you plan a wall drift you should start on top of the wall (which is what it seems was briefed - but what to do in case of a miss - and the likely cause of missing the top wasn't briefed). This intermediate stop depth is where your initial bailout decision is made. If you can't maintain this depth and swim back to the reef it's time to get buoyant and get started up.
2. The descent
When the dive leader saw the miss, she should have gathered her chicks right then and there, regrouped and gotten everyone to the top of the wall - my guess is that the miss was apparent from very early in the descent as things were already coming apart at 50' and the bottom wasn't as close as it should have been.
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I'm going to stop now - if I were writing this up professionally I can tell that when I got done I'd have quite a tome - but y'all were extremely lucky that someone didn't get killed on this dive. Extremely lucky.
Rick
 
I think Rick nailed that pretty good -

I have seen a lot of people get very comfortable in what they are doing - seems to me that the DM was treating this as a routine dive - obviously not - and that could have been mortal for someone.

I too would very much like to know what boat you were on and who the DM was - I have a personal interest in avoiding them in the future (like returning under my own power).

Cheers,
Terkel
 
Scary, very scary. Rick's got it right, you were very lucky everyone came back.

I too would like to know the group (send privately if you want), 'cause I'd be cautious ~ terrified(?) to go out where such a serious incident occurred.

What's your opion of what happened on the dive Beachman?
 
Hi Beachman

I have to agree with what has been said above, Rick has a good handle on the situation and hes pretty spot on.

In retrospect if you think that the DM was at fault (and lets face it you were there for the briefing and dive)then you have a duty to report the incident to the certifying agency. All agencies should be made aware of good and bad professionals within their agency, its the only way they police what their people are doing.

Not only that, but I'm sure the last thing you want is for this boat and DM to do the same again...because the next divers may well not be so lucky.

Regards

Hocky


 
I must say that when considering remedial action in a case like this - after all, neither the boat crew nor the dive leader purposefully endangered anyone - the after action action is key...
Did they learn their lesson?
Did they change the way they brief and do "wall/drift" diving?
Have they put out a "lessons learned" briefing to their whole organization, and to the dive industry in general?
If we can say "yes, yes and yes" then taking any further remedial action against the DM or crew would serve no useful purpose - indeed, it would have the chilling effect of squelching the free reporting of such incidents in the future, and the counterproductive fallout of not giving vital "lesson learned" information to DMs worldwide.
Rick
 
Not everyone can or does check this forum daily, so I'm going to wait to respond to your questions and requests to give others a chance to catch up.

When I do post again, I'll give you my opinions on the questions I raised and also give you the opinions of others who were there (to the best I can remember and interpret their comments and feelings about the incident).

This event occured in the morning of day 3 on a 5 day trip. We dove another 2 1/2 days without incident and I could not fault the cruise operation on any aspect of the trip except possibly the one disastrous drift dive.

I'll be out-of-pocket traveling until early next week, so don't expect anything until at least May 15th.
 
I will not dive with someone I don't know.I will not dive on a boat that someone I know hasn't been on .Period.Locality to locality these boneheads just incurred catastrophic liability by not following normal acceptable procedure.In some plces they could be liable for all med attention and then some.What was an OW with 12 dives doing on a dive of this type? Was the $ that important or was it a macho thing?
 
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