Fatality on Rosalie Moller wreck

[Altamira]

Any military and professional commercial pilot can confirm that continuous assessments of as many iterations and possible scenarios for emergencies and contingencies are extremely critical to successfully handling the problems when they occur. Even a couple of flight check rides a year are not sufficient to keep a pilot sharp enough to make the correct and timely decisions required in time sensitive and high stress situations. Unfortunately, most recreational hobbyists in dangerous activities will not spend the mental time needed to think about the "what ifs" before they actually happen.

 

[John the Pom]

...SNIP...

Concur that those were different modalities but both are based upon wrong decision making. But both incidents have a few common areas:
1. Situation awareness in both was lacking
2. Analysis of possible consequences was insufficient
3. Gas planning inadequate (evaluation of adequacies of reserves or gas available was not performed)

In both incidents the victim focussed on the task at hand (recovering an object) without the big picture. Worst when the more experienced team had time to make a decision while the less experienced just reacted. The former did no make use of team resources by communication and common sharing of the analysis of the task at end. The second team broke (no team integrity) when one team member correctly did not follow.

Just couple of my thoughts about the above.

Another interesting page below.
Clarifying multiple-mode decision making in conventional psychological models: A consideration of the influential mechanism of car use's characteristics on the behavioral use of public transportation - ScienceDirect

Yes - given the difference in experience between the people involved in the two incidents, the common aspects are quite thought-provoking ... Good post.

 

[ginti]

I beg to differ.....

Agree with your post, although some scientists would argue with the fact that only some animals have rational thinking

Sticking to the topic, one thing my tech instructors taught me is that, whatever happens, the first reaction to a problem must be to stop, stabilize, take a reference with the environment, call the buddies - then, one can think about what to do. Clearly, this does not work well in case of an out of gas scenario, but in all the other cases, it allows divers to take time to think and avoid overreactions. While this approach can nothing against complacency, it can save a life in situations like the one described by the OP if the diver has experience enough to make appropriate decisions.

 

[poseident]

Back when I was a kid learning deco from an old timer, the best advise he gave me......

Bob nails an important element here...my turn to get 'preachy.'

In most of the courses I have taken, (and hopefully in all the ones I taught,) the instructor says something very important. "You know know X, can do Y, and are aware of Z. Now you can go learn more." (Or something to that effect.)

Unfortunately this seems to be counter to the way people think about courses of all kinds (not just diving). "If I passed the test, I have demonstrated "mastery," is more the attitude, and sometimes qualifications get valued over experience. Here's where the opportunity to "learn from old-timers" can REALLY be beneficial. Those "I did this once--and I'll never do it again" and "I do this every time and it never fails" conversations are great opportunities to leverage a deeper pool of experience.

I THOUGHT I was great at spotting overweighted divers until my own "old-timer moment" when the boat captain pulled me aside one day, pointed at a few of my students and said "they are overweighted." When I countered with the typical young-instructor protests--"Their eye-level check was perfect!"--he said simply..."they have to kick to keep themselves on the surface...they are overweighted." He was right. I was YEARS into being a "pro" and I wasn't picking up on that signal (this works in the tropics....but not everywhere).

Point of the sermon...if you are reading this thread as a "lifelong learner," don't pass up on any opportunity to dive with/buddy up with/talk with anyone who's been doing this for a while. If they are willing to tell you something, it might be a good idea to listen.

 

[poseident]

The assumption that anyone would do what she did, is laughable.

The assumption that NOBODY would do what she did is equally laughable. If you've never seen someone do anything inexplicably risky while diving, you just haven't been doing it for long enough yet. (The same could go for any activity, I suppose)

I already expressed the opinion (as have others on this thread) that it's entirely possible the diver just "reacted." It wasn't a "decision" per se. My theory was that she was in a borderline state of panic and this was the snapping of the final thread.

 

[Bob DBF]

She was somewhat apprehensive before the dive, as she was using a borrowed computer she didn't know that well and was concerned about holding potential deco and safety stops. She was also over-weighted, owing to her concerns about not ascending in an uncontrolled fashion.

I already expressed the opinion (as have others on this thread) that it's entirely possible the diver just "reacted." It wasn't a "decision" per se. My theory was that she was in a borderline state of panic and this was the snapping of the final thread.

The decision was made on the surface, she needed the weight and so the die was cast. The trip after the weight was necessary, in her mind, I doubt if panic was involved, until later. Believing you have a hard stop, some are trained that a safety stop is mandatory, makes retrieving dropped weights a rational decision if you have learned no other alternative.

The real issue is that she did not look at other alternatives at the time of the accident, or more importantly, at the surface before the dive. This could be from lack of training, experience, or both.

At the time she was NDL (D. had 90 bar left in her tank, K. had 70. They were both within NDL.) so there was no reason for a deco stop and safety stops are not mandatory. She was free to make a direct ascent to the surface, and did not know it.


What divers should take away from this is that recreational training may not instill the knowledge and skill to make a basic lifesaving decision. It will be up to you to fill in the gaps with formal or informal training.

In NDL diving, when confronted with an emergency, make a direct orderly retreat to the surface. If one can reason out a better solution, fine but one does not have the air to stay underwater forever. When in doubt ascend.

Taking NDL divers on deco dives is setting them up for bad decision making in the event of an accident. I don't advise it without acquiring the necessary knowledge and skills to plan and execute a successful dive.

 

[vjongene]

OK, I guess that the discussion of this thread has more or less died down. Having been personally involved, I have a few more pieces of information and thoughts to share.
1. Several people asked if the SMB line that had been used for the descent was still in place. I am not sure if it was, but the instructions during the briefing were to make a drift ascent and to deploy one SMB for each buddy team so that the RIBs could find us. There was little or no current, so everyone surfaced within a rather narrow area. I don't think that anyone used the line for ascending, and the victim most likely didn't even know where the line was attached.
2. Much attention has been paid to the decision making process by the victim, but very little to the role of her buddy, K. I have a nagging suspicion that he may have played a direct role in the accident. He could have misinterpreted her signaling a cramp, which would have been unlikely to begin with since there was almost no physical effort involved in the dive. He may have bungled his intervention and inadvertently ripped out the weight pocket. He may have signaled to the victim that her weight pocket had fallen out, and even pointed down as it was falling. He may have panicked himself and precipitated events. I personally don't trust him to have told the whole truth after he surfaced. As I mentioned I had had a run-in with him after an earlier dive where he had behaved in an irresponsible manner, and he refused to acknowledge that he had done anything wrong. Others who had buddied with him pronounced him "unmanageable".
3. I have often seen people on Scubaboard stating that the only useful role of dive guides / DMs is to make coffee. In this thread, many faulted them for not having intervened either before or during the dive to discourage this buddy team from making the dive or to provide them with extra surveillance. The diving on this liveaboard was not advertised as being guided. and IMHO the DMs did perform their job well by giving good, detailed briefings and being present during the dives. Btw, there were no true beginners among the guests, just divers with different levels of self-confidence. I thought of offering the victim to be her buddy during this dive, because of her apprehensions, and maybe I could have prevented this chain of events. But I didn't.
4. After we docked in Hurghada, the police and the local court started an investigation of the accident. They interrogated all of the guests, as well as the DMs and some of the ship's crew. Together with the DMs, K. and two other guests I spent the night at the courthouse, mostly waiting to be let into the judge's august presence. They tried very hard to make us pin responsibility on the crew, on the DMs, or on the boat's owners and operators. Everyone said that they did their jobs well, and were not to blame. The case was finally dismissed. I fully expect that the insurance companies will take over now.
5. I went to the victim's funeral on Monday. The church was packed, and two priests showed up (one was a friend of the family). The victim was a universally loved person, active in her church and in civic life, member of local societies, and so forth. We should never forget that we are talking about real people here. I note that no one on Scubaboard was disrespectful.

 

[poseident]

Thanks very much for the additional information....

Your points about the potential for the buddy to have been a serious part of the problem are well taken. You had the direct experience with that individual, and we've all probably seen people like that and can relate to your impressions. It's unfortunate, but there are a lot of people out there like this diver. "What, me?!? I'm perfect!"

The part about the role of Divemasters is also important. That term means different things to different people, and the norms are different wherever you go. DMs everywhere are generally in a pretty precarious position. They may be "responsible" for the safety of divers that they have very little ability to affect in any way. They also may only think they are responsible for a narrow set of things specified by the boat operator ("Today I just need you to set the anchor and run a descent line, then get back to the boat to help clients"), while the clients THINK they are there to cater to their every whim, and then once something bad happens the courts (not to mention the court of public opinion) end up with a very different expectations. I worked as a Divemaster for many years and people didn't believe me when I say "those weren't fun dives. It was work."

As is almost always the case with accidents, this fatality was the result of several circumstances all coming together in a way that couldn't be overcome by the victim. Hopefully her friends and family took at least a little comfort from what sounds like a very emotional and reflective service.

I'm curious, did anyone there know who you where, and that you'd been there when the accident happened? If so, how were people reacting you your presence?

 

[vjongene]

I'm curious, did anyone there know who you where, and that you'd been there when the accident happened? If so, how were people reacting you your presence?

I got the distinct feeling that the family (husband and three sons) did not really want to know he details of what happened. The homilies mentioned a "freak accident", and concentrated on the positive aspects of her trip, in particular an encounter with Manta Rays that she had wanted to see for years. I was there with two other divers who had been on the boat, and we did not advertise our presence. However, the group prepared a booklet with photos and handwritten testimonies from most of the guests, which we will give to the family next week.

 

[poseident]

Thanks for the response vjongene. I hope the family appreciates the gesture from your group. It seems as though the group is staying in touch, and that's a nice thing.