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Complacency kills - It's not just an empty threat!

Discussion in 'Near Misses and Lessons Learned' started by hroark2112, Sep 11, 2018.

  1. hroark2112

    hroark2112 Tech Instructor

    # of Dives: 0 - 24
    Location: Raleigh, NC
    1,311
    1,228
    113
    I recently had a very near death experience at the start of a dive in Truk. I know it sounds dramatic but it is absolutely serious.

    The dive was on the San Francisco Maru. This was one of the wrecks I really badly wanted to see during the trip which means I guess I've got to schedule a return visit to do the dive again. I was in the second group jumping in the water and was on a CCR. The short version of the incident is that I jumped in the water and was preparing to dive. I took a breath and felt dizzy. I stopped and took another breath and thought to myself "I should get back on the boat!" The next thing I remember is waking up on the dive deck with people pounding on me and trying to jam a regulator in my mouth. I was able to get up and get inside to the AC, they put me on oxygen and brought me to ER where I spent a few hours sucking down oxygen, taking in an IV, and being poked, prodded and tested. Once I was safe to be released, I went to a hotel by the airport and rested until it was time to go home.

    Here's the timeline as given to me by one pf the divers on the boat directly involved in the rescue:

    850 entry
    855 non responsive at lift, jaw locked
    903 on deck non responsive weak pulse, bowels released
    905 blue coloration and limp still, forcing oxygen with jaw forced open
    908 white sputum no blood, dark blue, tiny pupils, turned in side, pushing stomach and chest to balance forced oxygen intake
    910 signs of breathing, jaw releasing
    920 responsive and irritable, small amount of phlegm
    935 refusing oxygen, moved to air conditioned room, bluish coloring
    1000 tired with slightly tight sternum, laying down, rotated again to side, able to breath on demand oxygen
    1010 light sensitivity and nausea without vomiting
    1030 arrival at hospital, transported on oxygen from boat, demand regulator. IV installed with .9% sodium chloride. Low oxygen notated by finger monitor of 89, increased to 96 and removed monitor
    1100 ekg completed and xray of chest he was able to stand with assistance.
    1105 complaining of cold and stiff on small gurneys. Wrapped in sheet and towel, resting.
    1110 drowsy with pink hue returning to face.
    1210 stood up and walked 10 steps to bathroom on own, light clear urine.
    1220 complaining of mild headache, onset/increase about 10 min ago. Does not desire anything to eat at this time. Confirmed desire to stay away from all narcotics. Turned on side, drifting off to light sleep.
    1400 checked into L5, resting in cool room, drank 1/3 bottle of water. Fruit smoothie, water and diet coke in fridge. Urinated almost clear.

    Now that all that is up there, here's the nuts & bolts of what happened & why.

    I had sent my unit in for annual service before the trip. Oxygen sensors were replaced, all the o-rings were replaced, first stages were serviced, all the hoses were replaced and the latest upgrade to the unit was installed. I got the unit back, but did not get an opportunity to dive the unit before packing it up for the trip. This was my first error. When we got onboard, I put the unit together and did all the necessary items on the checklist. The next morning, before the first dive, my computer was not connecting to the unit. I disconnected the cable, wiped the connectors and reconnected everything, and it worked. This problem reoccurred a number of times during the week. Error number 2. One of the first rules I was taught is very simple - never start a dive with a known issue. I did it anyway, kept an eye on it and for the first 5 days everything was OK. Then came the morning of the dive. The first group splashed followed shortly by my dive buddy. I grabbed my camera and put my Paralenz on the mask strap, and got into my gear. My buddy was in the water waiting for me, and I let myself start to rush. This is the next error, and where things really started to go bad fast. I opened the oxygen & diluent valves, verified my bailout was on, and checked my inflator. I put my loop in my mouth and went to the dive deck, and jumped in the water. The final error was that I did not verify my solenoid was firing. In my rush to get in the water, I breathed the PO2 in my loop down to a level that would not support life. The computer was not connecting (again) to the unit, and the solenoid would not fire. In my rush to get in the water, I did not manually add O2 and I did not notice my dropping PO2.
    The rest is history. My buddy saw me and called for help, and dragged me to the diver lift. The other divers on the boat pried my jaws open and forced as much oxygen as they could into my system, until I started breathing again. They got me out of my gear and got me to the ER as fast as possible.

    This specific incident took place on a CCR, but even open circuit divers need to be diligent with their dive planning and pre-dive preparations. There are plenty of things that can go wrong with your equipment, both diving CCR and OC. Allowing yourself to skip vital pre-dive checks can lead to fatal consequences.

    The only things that saved me from becoming a line on a crappy spreadsheet were the fact that I inflated my wing more than normal (since I had extra bailout) and the actions of the other divers on the boat. Had I been negative when I went in the water or had my buddy and the other divers onboard not been attentive, I would not have made it home alive.

    When I got back to the US, I sent the unit back in to the factory. The computer was replaced and the unit fully checked out. Once everything was verified to be operational, I took it out on a few dives. Obviously my pre-dive checklist was very thorough, I verified my solenoid was operating before even standing up to jump, and all systems were verified to be working properly.

    In hindsight, I learned a great deal from this incident. My future pre-dive planning and checklists will be done with this incident in mind, and if it takes me 5 more minutes to get in the water, so be it. I've always been good about replacing cells, and before this I was normally much better about my pre-dive. The bottom line is that complacency can and will kill you if given the opportunity, and there may be little to no warning that it is coming. The difference between life & death is a single breath, and I when I took the last breath and thought "I should get back on the boat!" it never crossed my mind to just drop my bailout valve from my mouth and take a breath of air. It seems so obvious now, but once I took that dizzying breath, my mind was unable to think of the obvious - there was no clear thought at all. All the training, all the skills practice, all the thoughts that "It will never happen to me" meant nothing, my brain simply did not tell me to do anything. There is very little time to react when things get to that point.

    Don't let it happen to you.

    Please note that I have left out the specific unit and the names of the others involved. The name of the unit is of absolutely no value here, since the human failures were of much greater significance, it could have been any unit and the scenario would not have changed. The other divers involved have my eternal gratitude, I can never repay them for saving me.
     
  2. Trace Malinowski

    Trace Malinowski Cave Instructor

    # of Dives: 5,000 - ∞
    Location: Alexandria Bay, NY
    2,325
    2,504
    113
    Wow! Glad you are okay. Thanks for sharing.
     
  3. BazzaB

    BazzaB Instructor, Scuba

    # of Dives: 500 - 999
    Location: Netherlands
    83
    45
    18
    Thanks for sharing indeed !
     
  4. hroark2112

    hroark2112 Tech Instructor

    # of Dives: 0 - 24
    Location: Raleigh, NC
    1,311
    1,228
    113
    Thanks! Probably the single most scary moment of my life.
     
    shoredivr likes this.
  5. txgoose

    txgoose Manta Ray

    # of Dives: 100 - 199
    Location: Houston
    768
    685
    93
    Thank you for sharing.
     
  6. Soloist

    Soloist Solo Diver

    # of Dives: 500 - 999
    Location: North Carolina
    891
    1,234
    93
    Thanks for posting this. Very well-written account of a truly horrific event. Very scary!
     
  7. Landlocked123

    Landlocked123 Barracuda

    # of Dives: 200 - 499
    Location: Reisterstown, MD
    448
    125
    43
    Happy you are ok. Really scary story.
     
  8. rhwestfall

    rhwestfall Solo Diver

    # of Dives: 200 - 499
    Location: "La Grande Ile"
    13,342
    12,929
    113
    :holysheep:
     
    hroark2112 likes this.
  9. Barnaby'sDad

    Barnaby'sDad ScubaBoard Supporter ScubaBoard Supporter

    # of Dives: 25 - 49
    Location: Virginia
    612
    312
    63
    Thank you for sharing.
     
  10. flyboy08

    flyboy08 ScubaBoard Supporter ScubaBoard Supporter

    # of Dives: 500 - 999
    Location: NYC
    3,173
    2,067
    113
    Yep, thanks for sharing and hats off to your first responders! I wonder if any had RD Card?
     
    Soloist likes this.

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