Student lost - Seattle, Washington

[Edward3c]

It would be helpful to make a list of all the major agencies that choose not to be members. By "major agencies," I am referring to the fact that there are more than 100 agencies, and the overwhelming majority are barely operational, if they are operational at all. Of the agencies whose names people would recognize, CMAS, BSAC, GUE, and UTD are not members. What others are you talking about?

I believe the agencies for which you teach are members, though. Why do you stoop to such a level?

Agencies like BSAC and GUE hold ISO certification so don’t need to belong to these outdated bodies; I include CMAS as it’s more like WRSTC than a training agency.

 

[John C. Ratliff]

I find it horribly distasteful that the system isn't reformed to provide more safety. My focus is on 7:2 ratio as reported as fact. That is permitted in standards. It shouldn't be. There will always be risk of death from medical emergencies. The loss of students should be exceedingly rare.

Okay, I’m an instructor from way back who hasn’t taught in decades, but something here is striking. You say a 7:2 ratio is okay. That’s 7 students to 2 instructors. But that’s an odd number. What happened to the buddy system?

Also, you throw around “WRSTC”; what the heck is that acronym?*

SeaRat

*I looked it up.
World Recreational Scuba Training Council - Wikipedia
This is the first I’ve heard of the World Recreational Scuba Training Council. The Wiki article was interesting.

 

[Biotech Diver]

Okay, I’m an instructor from way back who hasn’t taught in decades, but something here is striking. You say a 7:2 ratio is okay. That’s 7 students to 2 instructors. But that’s an odd number. What happened to the buddy system

Also, you throw around “WRSTC”; what the heck is that acronym?

SeaRat

He thinks 3 students to one instructor in a shallow night dive with no current is completely unacceptable and the reason the student drowned.

 

[John C. Ratliff]

The only information we will receive is the autopsy report. If I'm not mistaken, when the OW student was lost at Cive 1 five years ago, the autopsy report was drowning. No other information was given that could be used to mitigate such future events.

Hence we are left with speculation. Placing blame on individuals as is often done doesn't seem to be working. A more productive approach is looking at the system in which the instructors were operating. At least this is what I learned from Gareth Lock's Human Factors workshop. And that's what I've attempted to do in this thread.

Did anyone impound and analyze this diver’s equipment? That would be a start. The autopsy report may or may not be helpful. If there was a dive computer involved, did anyone download the dive profile? That would give us an idea of what actually happened too.

I have been in professional safety a long time, almost as long as I’ve been diving. I don’t have real knowledge of current dive instructor practices, as my NAUI manuals date to the 1970s and 1980s. However, it is pertinent to determine, since this was an instructional dive, what the instructor’s insights are to this accident.

The other thought is that in professional safety, I have for years tried to get people away from a single root cause; inevitably there is a sequence of happenings, and therefore root causes (plural) which come together to cause the accident which may become a fatality.

SeaRat

 

[Biotech Diver]

I’m sure someone has the answers to these questions but sadly it may never be shared. The instructors may have been negligent or maybe they did nothing wrong and it was just a tragic accident. I’ve done investigations in my line of work tor many years and the one thing I always stress is to go into the investigation with as little bias and preconceptions as possible because if you don’t you could follow the rabbit down the wrong hole. You have to keep an open mind and follow the data and facts and leave your personal opinions behind. Monday morning quarterbacking is an expected bias but it needs to be kept in check to prevent the investigation from coming to the wrong conclusions.

 

[Bob DBF]

He thinks 3 students to one instructor in a shallow night dive with no current is completely unacceptable and the reason the student drowned.

Probably more like, 3 students to one instructor in a shallow night dive with no current is completely unacceptable, because it is quite easy to be separated from the student. Whether this was the cause of the accident is another issue, which would be a lot easier to determine if the instructor was not separated from the student.

 

[wetb4igetinthewater]

He thinks 3 students to one instructor in a shallow night dive with no current is completely unacceptable and the reason the student drowned.

First, you don't speak for me. Second, that's not at all what I said (or think).

 

[wetb4igetinthewater]

Okay, I’m an instructor from way back who hasn’t taught in decades, but something here is striking. You say a 7:2 ratio is okay. That’s 7 students to 2 instructors. But that’s an odd number. What happened to the buddy system?

Also, you throw around “WRSTC”; what the heck is that acronym?*

SeaRat

*I looked it up.
World Recreational Scuba Training Council - Wikipedia
This is the first I’ve heard of the World Recreational Scuba Training Council. The Wiki article was interesting.

Did anyone impound and analyze this diver’s equipment? That would be a start. The autopsy report may or may not be helpful. If there was a dive computer involved, did anyone download the dive profile? That would give us an idea of what actually happened too.

I have been in professional safety a long time, almost as long as I’ve been diving. I don’t have real knowledge of current dive instructor practices, as my NAUI manuals date to the 1970s and 1980s. However, it is pertinent to determine, since this was an instructional dive, what the instructor’s insights are to this accident.

The other thought is that in professional safety, I have for years tried to get people away from a single root cause; inevitably there is a sequence of happenings, and therefore root causes (plural) which come together to cause the accident which may become a fatality.

SeaRat

Law enforcement (I believe it is the sheriff's department that usually handles this, I'll check on who does as my buddy on the King County sherriff's department has a friend in the marine unit who wants to dive with me) always has equipment inspected. And I know who does the inspection for LE, but we will likely never see that information.

We will likely never see what the autopsy report says, nor any information on any dive computer.

We will likely never see the testimony from the two instructors nor the six surviving students.

We don't know and we will never know if this was a group dive (which has led to fatalities before with a group from Oregon not noticing someone was gone like in Les Davis some years ago) or a breakdown in the buddy system.

What we do know is that there was a 7:2 ratio. That means that each instructor needs to account for the wherabouts of 7 students and the other instructor to make sure they are all together. It doesn't matter if it was a buddy system or a group dive, the instructors still need to maintain control. We do know the dive site and what it is like (some of us at least). Now if people are curious what viz is like, while these numbers are people's estimates and not using a Secchi disk, they are a good indicator as to how poor viz can be: pnwdiving.com. Cove 2 has a silty bottom and the silt clouds do not disperse quickly. Combined with poor viz, keeping track of 8 lights for 45 minutes to an hour has a level of risk. When I first started out teaching and I was teaching on the knees (so my students were overweighted and had bad buoyancy), I quickly started giving my students dive lights for safety. Even then, they'd kick up enough of a silt cloud that their light disappeared. So I'd swim into the silt cloud to find them and pull them out. Even in good conditions I wouldn't want to keep track of 8 lights, not even if I was in the crystal clear waters of the Aegean. I want to see all of my students' lights at the same time. That's why I believe that the standards regarding ratios need to be updated.

 

[Biotech Diver]

Does anyone know what the class was being taught? I would assume it is a night diving course? I completed my night diving course in Monterey about 16 years ago as part of my advanced certification. I was also completing my dry suit certification simultaneously. Depth was probably about 40 feet max and visibility wasn’t more than 15 feet (at best) and water temperature was probably 48-50F. I don’t recall the exact ratio of us students to instructors but it was greater than one instructor to two students, and as far as I know, this was pretty common.

All of us students were already open water certified with varying levels of experience. We all had dive lights and all of us had at least one glow stick attached to our tanks or the back of our BC’s. This type of scenario played out time and time again on a regular basis by many different dive shops and instructors and I don’t recall any tragedies similar to this one in Seattle.

Everyone, including dive instructors, has their own risk tolerance. If it were possible to compile statistics on the number of times night dives with a ratio of 1:3 or 1:4 instructor to student ratios were carried out without incident, I suspect you would be close to a six sigma success rate.

You build your process based on risk levels and risk tolerance. You make adjustments based on trend analysis. You wouldn’t typically change your whole process for one event unless you find a gap during your investigation. You can also never guarantee 100% success 100% of the time no matter how many safeguards you implement.

Diving has inherent risks and sometimes even the best planning and precautions are not enough for even the most experienced divers. With the information available to the general public and diving community, all we can do is speculate on what went wrong and why. I’m not defending the instructors because I have no idea who they are or what their reputations are. All I can say is that their ratio of students to instructors are not an anomaly. Maybe it should be or maybe it’s an isolated event or maybe everyone has just been lucky again and again and gotten away with it. I really think it’s a case by case basis and a judgment call by both the instructors and students in each and every case. I’m not going to draw a hard line and say ratio X is always unacceptable because before you know it ratio X soon becomes too unsafe and then where do you go from there? Two instructors to one student? Three to one? $0.02

 

[Tripp]

Just a reminder, Explore_DMC on page 7 of this thread said that it was described as two separate groups. One with an instructor and three students, and the other with an instructor and two students, one being the victim. I just wish we had more facts. Without them it will be hard to postulate any cause:effect relationship at all.