3 unaccounted for after a flooded magnesite mine 'Maria Concordia' dive in Poland

[admikar]

Of course I am not going to blame them for trying rescue. After all, it is they that paid the ultimate price.
I did my fair share of stupid rescues

 

[lermontov]

Some of you have contributed very insightful observations. They made me conclude the following (my pure conjecture):

1) Instructor knew full well where he was - he was teaching courses in this very area, I bet you he could get out of there anytime in any visibility, with no line or compass (it is a tube).
2) The autopsies did not reveal any trauma - there was no 'fighting'.
3) If you look at the YT video I posted showing the wooden frame area (the 1st video), you will see that there is an air pocket just before the wooden frame. I think this is where Student 1 and Instructor decided to 'breathe' and that's why their helmets were found there (it is easier to stick your face to the narrow air pocket without a helmet).
4) Using the air pocket could have been a way of beating the total silt out in order to communicate or check compass/map etc, as well as breathing the atmosphere that sustains life.
5) Student 2 took an oxygen tank with him through the stone dam during the rescue attempt to purge the air pocket, which due to breathing would contain more and more CO2. If purged with air, the O2 concentration would always be below 21%. With oxygen, the O2 concentration in the breathable pocket was being enriched to levels supporting life.
6) Student 2 left stages before the stone dam as he knew the team would need them to surface and do deco. It was impractical for him to squeeze with all four through the stone dam (the videos I posted contain sequences of divers squeezing through a stone dam before they reach the wooden frame - that could be the stone dam in question, it is not too wide).
7) Student 2 laid a line from the wooden log to the T area to prepare evacuation or show the way for the rescue team.
8) I believe Student 2 honestly believed the rescue party is coming very soon - there must have been discussions on the surface between the Observer and Student 2. Note, that the Observer did go into the water again after Student 2 went to look for missing divers. The Observer did not go past the dam though.
9) The Instructor did not want to leave the panicked student alone and stayed with him hoping for the rescue to arrive - he knew there are 5 divers on the surface who know they are in trouble, it would not have been totally irrational thinking.
10) What caused the initial bolting to the air pocket of Student 1 and subsequently the Instructor is unknown, probably panicking. Note that if you remove gear in zero vis there is zero chance you can find and put it back even if someone brings you a tank with air, which in that scenario were not even full.

I think we are looking here at two heroic efforts of Instructor and Student 2 to rescue Student 1. Unfortunately, they ran out of air as they did not have any fresh tanks at the surface and the rescue party never came.

those sound reasonable assumptions - if we assume student 2 reached them then they likely discussed some sort of plan in the air pocket -after a long wait and no rescue student 2 may have decide to go back and get the dropped tanks or he may have decided to go back regardless and maybe lost the line or got tangled in it himself and ran out of air -terrible terrible scenario.

 

[Pearlman]

Some of you have contributed very insightful observations. They made me conclude the following (my pure conjecture):

Someone done a lot of unselfish work ferrying stage bottles back into the system to the tee. That’s the actions of a cool head and someone that knew what he was doing. Unfortunately it didn’t pay off however well intended.

Thinking about the final hour of these divers and how they coped with the terror and impending doom makes my hair stand on its ends and reading this thread unavoidably plunges me into dark and gloomy thoughts. @Hiszpan’s storyline though shines a light cutting through the darkness of my emotions.

Very easy to say bad or poor judgement, but I would prefer thinking about it as the instructor and student2 doing their best in reacting to the situation of a possibly panicked diver starting a chain reaction of events that threw all the earlier calculations totally out of gear.

Leaving aside the error of judgement around human factors of safety planning for a moment, I am afraid we are looking at a tale of untold heroics and bravery of these divers in their final moments that will never surface and penetrate our conscious memory if we merely look at the final outcome and analyse the never-do’s and donts as mistakes with cold and calculating minds seen in retrospect.

In Hollywood the heroes usually come out alive to celebrate their tales with the audience… This real life story unfortunately had the darkest and gloomiest of outcomes.

 

[Hiszpan]

Of course I am not going to blame them for trying rescue. After all, it is they that paid the ultimate price.
I did my fair share of stupid rescues

Could you imagine making a similar decision as Instructor and Student 2 as one of your ‘stupid rescues’ scenarios?

 

[admikar]

Could you imagine making a similar decision as Instructor and Student 2 as one of your ‘stupid rescues’ scenarios?

That is a hard one. I have no idea how I would react, since I never was in a situation like that.

 

[iwona_76]

As the managers of the mine, we commissioned a report to determine the causes and course of the accident. The report was prepared by Witold Hoffmann - diving instructor, speleologist, cave explorer. He took part in the recovering the bodies.

The Polish version of the report appeared at the end of April this year. Now the English version has been created. Take time to read and analyze.

The report can be downloaded from our website, in Polish and English: Informacja – Maria Concordia

(reports for download in PL and En versions at the bottom of the page)

 

[lermontov]

As the managers of the mine, we commissioned a report to determine the causes and course of the accident. The report was prepared by Witold Hoffmann - diving instructor, speleologist, cave explorer. He took part in the recovering the bodies.

The Polish version of the report appeared at the end of April this year. Now the English version has been created. Take time to read and analyze.

The report can be downloaded from our website, in Polish and English: Informacja – Maria Concordia

(reports for download in PL and En versions at the bottom of the page)

Im pleased youve done this - Its important to stop trying too brush these things away from fear incrimination or bad publicity, bring them out for scrutiny allows us to all learn and not make the same mistakes and be grateful it wasnt us- RIP

 

[Manatee Diver]

Reading through that, the lost diver and unconscious diver drill were also combined along with unbreifed. Granted my instructor had an instructor intern that was "running" the class, so I was always supervised even when he swam off to be a bad buddy.

 

[iwona_76]

Below I also present the official statement from the government prosecutor's office (translated by Google, sorry for any mistakes):



„On June 30, 2022 at 11.00 at the seat of the District Prosecutor's Office in Wrocław, a briefing was held on the issuance on June 21, 2022 by the District Prosecutor's Office (...) of the decision to discontinue the investigation into the immediate threat of loss of life or serious damage to health of 4 course divers by a diving training instructor Maciej M.

(…)

The forensic medical section commissioned by the prosecutor showed that drowning was the cause of the sudden and violent death of all three divers. There was no evidence of lesions or injuries that could explain death.

A number of evidentiary activities were carried out in the course of the investigation, incl. witnesses participating in the training, victims of the case, participating in the rescue operation were questioned, the diving equipment was secured and tested, and a team of experts from the list of the District Court in Gdańsk was appointed in the field of diving safety and underwater works, cave diving and hyperbaric medicine.

In the opinion of experts, the event was triggered by massive blurring in this section of the corridor of the flooded tunnel, resulting from the unfavorable choice of the exercise site (a large number of people in one place and the geology of the site), their form (expert level exercises) and possibly insufficient experience of individual members of cave diving.



The investigation showed that the person responsible for supervising the students was the instructor Maciej M. He was under a special obligation to take care of the trained divers and his behavior through inappropriate organization of diving, i.e. planning complex and multi-task exercises exceeding the current competences of students, selecting the place of exercise inconsistent with regulations of the mine and IANTD standards as well as making wrong decisions during the dive, i.e. not interrupting the training when visibility deteriorated, led to an accident, which resulted in the death of two students and himself - a diving training instructor.



In connection with the above, the Prosecutor's Office discontinued the investigation:

- in the matter of exposing two students to the immediate danger of loss of life or serious damage to health and, consequently, as a result of the behavior of Maciej M. of the diving training instructor, their death, i.e. for the act of art. (...) - in view of the death of the suspected person,

- in the case of exposing the next two students to the immediate danger of loss of life or serious damage to health by Maciej M. diving training instructor, i.e. an act under Art. (...) - in view of the death of the suspected person (…)”

 

[cathal]

Bit of a one dimensional conclusion imho. What about the culture within the training agency? Why did the instructor feel that he could get away with this sub standard practices. If the Training Agency were rigidly ensuring that their own standards were being correctly applied would these deviations in practice have occurred. Should the standards and practices of the Training Agency been examined as well??