Article on Death In Ginnie Springs

[abnfrog]

Re-read Jim Lapenta's last post, it should clarify it for you. He took two tanks with O2 to the Doria and used one, the other he did not use. The one he used was then filled with air for the cave trip so he now had two tanks marked with O2 one of which was now filled with air. He took one of those tanks to the caves thinking it was the one filled with air. He was wrong.

I have no first hand knowledge but that is what I read in Jim Lapenta's post.

geez thanks for clearing that up for everyone .......

 

[Rosborne]

Yeah, you really don't know what you're talking about. Which is okay. You're not really part of what happens here. The gas is tested on the surface by the people who manage the recovery, not for nothing, but so that they can do accident analysis. This is mostly for the IUCRR's knowledge, not the authorities. Since there's no way to put a contaminant into a scuba bottle at the site, there's no change in forensic evidence. All of the pertinent equipment is then taken by the Sheriff/ME for their investigation. Tanks are often sent to a lab to be analyzed for contaminants, oxygen content, CO, etc. The equipment is held for quite some time until the police do their investigation. For example: A few years ago, when the lady died at Blue Heron Bridge (with rented equipment from my shop) the sheriff's department confiscated all gear. It wasn't returned to us until more than a year later.

One last point.... it wasn't air that was tested. Had it been air, Carlos would still be alive.

With respect--you're wrong. I talked to the police about what happened to the gear, they didn't take it and they didn't test it. I may not be aware of what is supposed to happen, but I know what happened in this instance.

---------- Post added January 30th, 2015 at 09:30 AM ----------

I think at some point you have to accept Carlos took a bottle filled with poison diving. If you can allow this to be a human factors accident, it becomes very clear what happened and who is ultimately responsible.

Your requirement for a CSI inquiry would be quite relevant if another party had motive and secretly swapped his tanks, or refilled his gas after he analyzed them in an effort to purposefully kill him. Sadly, the tanks were easily traced back to the prior dive on the Andrea Doria. Carlos failed in his responsibilty as a diver, and the best you could hope for in a trial is assignment of blame by percentage. There are a lot of people who might assign that blame at or near 100% to Carlos as he was soley responsible for checking that gas. Using witness statements - he didn't do it.

Let's assume the evidence that is intact, on-site expert statements, on-site eye witnesses, and immediate on-site gas analysis are all flat wrong. In other words, let's assume all the forensic evidence is gone. We're left with the Medical Examiner's report, and we learn from that a healthy adult male died from drowning. We trace the gear back and discover it was filled by Carlos for another dive and repurposed. We would discover that Carlos did not analyze the gas after filling the tank, and we would probably learn the gas was not marked consistent with the conventions (name, fill date, etc.) We would also learn that Carlos had physical possession of that gas, and transported it to Florida where it remained in his possession until the time of use. Skip everything that happend on the dive, skip the post gas analysis, skip the dive team statements, skip the expert cave instructor's statement, skip the on-site gas analysis. Fast forward to the ME's letter of opinion on the drowning.

Seems like Carlos didn't play by the rules long before standing on the shores at Ghilcrest County, FL and the accident had begun weeks or months before. It was imperative he break the accident chain by taking :30 seconds and analyzing the gas. But it's clear he didn't take half a minute and check that cylinder and he paid for it dearly.

A much more interesting article might have looked at one of the 5-Dangerous Attitudes of pilots. Get-There-Itis comes to mind and has killed many a pilot. The reward of getting things moving quickly overcomes the mundane safety items that seem unnecessary, but checklists and procedures are there to stop bad human behavior - to break the accident chain. In this case, had Carlos followed the rules of a recreational Enriched Air Diver, he would have rejoined his family at Disney World. Afterall, the Medical Examiner seems to think so...

All excellent points. If only the police had taken the same methodical approach I would have been content.

---------- Post added January 30th, 2015 at 09:30 AM ----------

I think at some point you have to accept Carlos took a bottle filled with poison diving. If you can allow this to be a human factors accident, it becomes very clear what happened and who is ultimately responsible.

Your requirement for a CSI inquiry would be quite relevant if another party had motive and secretly swapped his tanks, or refilled his gas after he analyzed them in an effort to purposefully kill him. Sadly, the tanks were easily traced back to the prior dive on the Andrea Doria. Carlos failed in his responsibilty as a diver, and the best you could hope for in a trial is assignment of blame by percentage. There are a lot of people who might assign that blame at or near 100% to Carlos as he was soley responsible for checking that gas. Using witness statements - he didn't do it.

Let's assume the evidence that is intact, on-site expert statements, on-site eye witnesses, and immediate on-site gas analysis are all flat wrong. In other words, let's assume all the forensic evidence is gone. We're left with the Medical Examiner's report, and we learn from that a healthy adult male died from drowning. We trace the gear back and discover it was filled by Carlos for another dive and repurposed. We would discover that Carlos did not analyze the gas after filling the tank, and we would probably learn the gas was not marked consistent with the conventions (name, fill date, etc.) We would also learn that Carlos had physical possession of that gas, and transported it to Florida where it remained in his possession until the time of use. Skip everything that happend on the dive, skip the post gas analysis, skip the dive team statements, skip the expert cave instructor's statement, skip the on-site gas analysis. Fast forward to the ME's letter of opinion on the drowning.

Seems like Carlos didn't play by the rules long before standing on the shores at Ghilcrest County, FL and the accident had begun weeks or months before. It was imperative he break the accident chain by taking :30 seconds and analyzing the gas. But it's clear he didn't take half a minute and check that cylinder and he paid for it dearly.

A much more interesting article might have looked at one of the 5-Dangerous Attitudes of pilots. Get-There-Itis comes to mind and has killed many a pilot. The reward of getting things moving quickly overcomes the mundane safety items that seem unnecessary, but checklists and procedures are there to stop bad human behavior - to break the accident chain. In this case, had Carlos followed the rules of a recreational Enriched Air Diver, he would have rejoined his family at Disney World. Afterall, the Medical Examiner seems to think so...

All excellent points. If only the police had taken the same methodical approach I would have been content.

---------- Post added January 30th, 2015 at 09:34 AM ----------

So, Rosborne, you are saying that unless evidence from a diving accident reaches the standard of the criminal courtroom, you don't accept it as having any validity? You remind me of the defense attorney who finds a weakness in the evidence chain and uses it to get an acquittal of someone everybody, including his own attorney, knows is guilty.

I don't buy a conspiracy theory. I don't buy a deliberate attempt by anyone to blacken Carlos's reputation. I do buy that reasonable evidence obtained by reasonable people matches the description of the event, and everything I learned about the man (both from public and private sources) said that this behavior was consistent with his temperament.

I don't believe in any conspiracy theories. I do think its not unreasonable to expect police to follow standard procedures and make a reasonable effort to investigate. Much was assumed and as a result, much was lost. Carlos probably didn't test his gas properly and as a result died--probably.

 

[abnfrog]

It doesn't take a rocket scientist to see exactly WHY he would do those things...he was reckless.

As tech divers it is good to remember that cavalier attitudes and being "John Wayne" will eventually kill you...as it did this guy.

actually john wayne said "life's tough...its tougher when your stupid "

 

[Rosborne]

We do know- with relative certainty- what happened.

During suit up witness/buddies saw him with a stage of O2.... The label said oxygen.

Witnesses/buddies asked him to analyze.



He did not. He Stated he knew contents were Air.

Witness buddies observed him suffer an Oxtox seizure.

Gas analysis at scene at time of incident showed the stage bottle contained 98% O2.

Darwin prevails.

Forensic analysis was unnecessary because the obvious cause was user error. No one planted a fake label on a bottle of O2. He wasn't ambushed in the cave. No one drowned him.

To suggest "we'll never know what happened" is fanciful at best maliciously inaccurate in reality.

No one needed to do a detailed forensic analysis of the cause of death of the diver because there was a clear chain of the accident causation.

Unless you have reason to believe: 1) all the witnesses lied 2) the analyzer was completely inaccurate, 3) the instructor didn't know how to use it or lied about the reading, or 4) that the bottles were switched before analysis... Where is the unknown variable?

Knowing with "relative certainty" is not knowing at all. It's like being partly pregnant.

 

[Jim Lapenta]

Why would the police test it? They are for the most part clueless about stuff related to dive accidents. This is why they rely on "experts " who also happen to be cave instructors, dive shop owners, and the like. There was no need for the cops to take the gas and gear. There was no evidence or indication of foul play. Unless you have suspicions based on unknown to the rest of the world details? His disregard for basic safe diving protocol killed him. If you have evidence to the contrary spit it out man. Or pass it on to the cops. Don't go all Weekly World News on us with bs articles and theories.

 

[HIGHwing]

geez thanks for clearing that up for everyone .......

I will say it again, I always rip the stickers off all my bottles when I'm done diving for a reason. I quite literally started that procedure from the lessons learned from Carlos' accident. That's what the article should have been about. Better procedures to force yourself to analyze, team analyzing/cross-check, or even borrowing from the CCR community - the dreaded checklist.

I did not know Carlos, but from what I have learned this particular accident falls into the category of the first time he got caught. Seems he'd made similar mistakes many times before, perhaps instilling a cavalier attitude in his dive groupies and others. Shame, really.

 

[tomfcrist]

actually john wayne said "life's tough...its tougher when your stupid "

True...but he also participated in firefights in most of his movies...in a solid majority of his movies he was slinging rounds downrange while standing tall and trying to be a hero. In the real (non Hollywood) world, those actions will ensure you get the next medevac. Hero's die....that's what they do.

 

[Doppler]

Knowing with "relative certainty" is not knowing at all. It's like being partly pregnant.

That is simply not the case. There are ample situations in which we function and make life decisions based on relative certainties. You have probably done a bunch of things today based on the relative certainty that doing so will not put you in harm's way and will help you to accomplish what you need to.

I believe I understand how profoundly your friend's death has affected you; and perhaps with relative certainty, understand how shaken you are still by his demise.

The facts surrounding diving accidents are very seldom simple, and are rarely shared with the community at large. Yet, we learn from them what we can, and those of us who teach, attempt to cobble together accident analysis modules for our presentations, and articles, and books based on those lessons. (Ironically, I have just put the final touches on a presentation for an event this Saturday... it is called staying safe, and I am reasonably sure several people in the audience will have known or at least heard about your friend's death. Not sure where you are in Canada but you are welcome to attend... it is in Ancaster.)

In this case, all the facts the community at large needs to know ARE known... we do not need a police investigation to confirm them... we simply need to accept them. Furthermore, we do have an excellent opportunity to learn from what we know. A diver is dead because he made a preventable error. He died by misadventure: a wonderfully descriptive English quasi-legal term which describes someone doing something outside the purview of accepted practice. He died because he breathed from a cylinder containing the wrong gas for the depth he was at. The cylinder was labelled as a decompression cylinder (it was a dedicated oxygen cylinder), and that label alone should have prevent its use as a stage bottle. I'd suggest it is sloppy practice to do so. Germane to the accident analysis, it contained a gas whose oxygen content at the beginning of his dive was disputed. He chose to ignore best practice and, rather than analyze its contents, opted instead to breath it. Inexperience kills new divers... Complacency kills experienced divers. These were the actions of a complacent person.

The lesson is clear, and I hope, when anyone reading this thread is tempted to fudge or ignore best practice and dive a gas whose content is unknown or in the slightest doubt, they remember this lesson.

 

[decompression]

Well said, Steve.


Sent from my iPhone using Tapatalk

 

[abnfrog]

something my old layer said to me years ago (hes a judge in the general divsion now , guess he was too effective defending ) that might be aprapo here ...never trust a cop or a reporter ...."they try to make something out of nothing thats their job "