TSandM: Missing Diver in Clallam County, WA

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.That's what is puzzling to me too.But whatever "happened" would have had to have occurred just after Peter last saw her, or already happening but was not obvious to Peter.My reasoning is that she would have gone through the exact same buddy-separation drill as Peter did, just as soon as she realized she could not see Peter, which I'd guess would have occurred at about the same time Peter noticed Lynne was "missing". Logically they should have surfaced at almost the same time.Putting catastrophic health events aside for this question (even though I think that a sudden health issue is still the most likely cause), and being very clear that this is wholly speculation, for those who know her typical equipment configuration:

Is there any single equipment failure that could have prevented her from surfacing? Is there any failure that could account for a rapid, un-correctable loss of buoyancy?

Could
a drysuit inflator failure result in a a rapid descent and a suit "squeeze" significant enough to prevent her reaching her wing inflator? Thanks.
These are good questions. In the safety profession, there is a Process Safety Management technique called a "What-If Analysis."
APPENDIX VI-

The What-If Analysis technique is normally used in a pro-active manner to define process problems before they actually occur, using the Piping and Instrument Diagrams (P&ID). But it can be an accident analysis tool when the sequence of events are incomplete. So with this in mind, and acknowledging that this question is based upon incomplete information, here is my question:

What if Lynne was not trying to dump air from her dry suit when last seen, but instead was trying to cope with a catastrophic failure of the arm relief valve/vent, which had come apart and the suit was flooding? What would be the consequences? Likelihood is very low, but would this seems to fit the circumstances described. This would be a single-point failure, and those are things design engineers try to design out so that they cannot happen. Such types of failures have apparently happened in the past:

https://cpsc.gov/en/recalls/1988/dui-dry-suit-ac-valve-recalled/

CPSC, Trelleborg Viking Announce Recall Of Air Inlet Hose | CPSC.gov

Search Results: drysuit recall

Any thoughts?

SeaRat
John C. Ratliff, CSP, CIH, MSPH
NAUI #2710 (retired)
 
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She would be getting very cold, very fast but she still has her wing for lift. I've had one bad suit flood (neck seal) when I was a long way from shore on a shore dive.

It's very cold and she would be making her way to the surface (and the boat). Since it came just after a downdraft it's (much) more likely that she was venting of course.
 
A full suit flood would have been managed by a diver of Lynne's skill.
The key factor in all of the speculation so far is : time.

Whatever happened, took place extremely quickly. A flood takes time and you get colder and colder but you do not become suddenly negative buoyant.

How cold you get will depend on the circumstances - a hole in the suit takes time to flood and you can adjust buoyancy quite easily.

A valve takes even less time and of course you get colder more quickly - buoyancy is affected more quickly but again can be managed even with cold hands - the probability of a catastrophic failure in Lynne's case I think is very low.

I'm pretty sure she would have been very meticulous in her pre dive inspections and that she had stated on numerous occasions that she had a low cold threshold.

In answer to John C Ratliffs question I think Lynne would have had time to collect her thoughts and deal with the situation - she might have felt cold and stressed but her previous training and experience would have kicked in.

I really don't like to speculate as there are so few actual facts but I do wonder if Kevrumbo's hypothesis of C02 extertion coupled with vertigo might have had a role to play.
 
No way a drysuit valve failure would lead to loss. Plenty of buoyancy in the wing/bcd, and it takes time for a suit to flood. Not a biggie.
 
I was recently involved in another A&I "discussions", and it is painful and frustrating so see these threads begin to descend to bickering, finger pointing and :soapbox:

We need to remember that whenever a diver is lost family, friends, fellow divers ARE going to come here, looking for answers. Answers we may never have, but answers it is almost always going to be too soon to have, definitively.

People, fellow divers, are hurting, and venting. Some are posturing. Or posing, but that is just how some folks are. I tried yesterday to get folks to realize that they do not have to get sucked into arguing with every misstep, :gas: :troll: :soapbox: that comes into the thread.

You can't really keep the creeps out of a discussion like ours, but you can exclude them from your discussion, by ignoring them if they are adding nothing of value.

---------- Post added September 2nd, 2015 at 09:18 AM ----------

Before anyone gets their panties in a tight wad, I am not referring to any specific post or poster, but to a general trend within these threads.

---------- Post added September 2nd, 2015 at 09:21 AM ----------

http://www.scubaboard.com/forums/ac...ents-incident-threads-victim-perspective.html
 
Well, thank you Bob. I wish you would take your own advice and not speculate. You know Lynne so well you even know what she was (or wasn't) thinking on this dive although you weren't there. You also confuse the reception of stressors which can't be controlled with as you say "practiced" skills. Having the skills to deal effectively with stressors doesn't prevent them from occuring but reduces their impact and leads to their elimination (assuming the correct action is taken).


The difference, of course, is that I'm relating things I've observed over 10 years of diving with her ... diving is, after all, very much a behavioral activity in which we tend to follow routines in response to circumstances. This was particularly true with Lynne, due to the nature of her personality. And I knew her routines and personality quite well.

You, on the other hand, have never met her, and are relying on rumors you read on the internet about how she dived that have no basis in reality.

I'd ask you ... as Peter and others have ... to please not do that ... it adds no value to the conversation.


Yes, we shouldn't ascribe to her traits she may have or not have as you have done above on that fateful dive..... that is speculation. The fact she was observed with those traits only supports the fact (which I wholeheartly agree) that she was an experienced highly skilled diver ON THOSE DIVES YOU OBSERVED HER.

One does not, suddenly, lose their experience or skills on a particular dive ... those are earned and ingrained, and relied upon in times of stress. Lynne was obsessive about practicing her skills to the point where they became as instinctive as walking ... once sufficiently learned it's not something you have to put conscious effort into.

... Bob (Grateful Diver)

---------- Post added September 2nd, 2015 at 07:26 AM ----------

I have never used a dry suit. If a diver is vertical and venting a dry suit, I assume through a raised arm, and a severe medical event (like a heart attack) occurs, does the venting action stop or continue?

The air bubble will rise to the highest point of the suit. If that point allows it a path to the dump valve, it will continue venting until the air pressure inside the suit equals the ambient water pressure outside ... at which point the latter will push the diaphragm in the dump valve closed and venting will cease.

... Bob (Grateful Diver)

---------- Post added September 2nd, 2015 at 07:31 AM ----------

Some events are more likely than others but all are just speculation until more evidence develops. I hope we really don't need to speculate as to whether Lynne was prepared for the dive or had the skills or training but at the same time, have to remember that not everyone had the same understanding of her and Peters abilities. Most of all, I can imagine her responding in a an intelligent and civil way and making her points based upon there merits.

... bears repeating ... thank you Dale ... very well said ...

... Bob (Grateful Diver)

---------- Post added September 2nd, 2015 at 07:34 AM ----------

Is it possible that there was some unknown injury from the equestrian accident 3 days (I believe that was the time frame I read) before that last dive that was aggravated during the rapid descent, ascent and likely physical exertion that occurred during the dive?

That thought also crossed my mind. Lynne was many great things ... but she was still 61 years old. None of us can stop the cumulative effects of wear and tear on our bodies as we age ... and many of us (self included) have a real hard time understanding that we simply cannot get away, physically, with things we did when we were younger.

But in this case there was a known injury. I have to think that Lynne would have considered that injury based on her medical background and decided that it was not sufficient reason to scrub the dive. Lynne, more than anyone else I ever met, lived by the maxim "there's always another day to dive". I've seen her call dives before that I knew she really wanted to do because conditions or circumstances didn't meet what she considered acceptable criteria.

... Bob (Grateful Diver)
 
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I can't say that I amassed a large number of dives with Lynne, but I did dive with her in three countries in three very different conditions. We have also had many private conversations via email over the years. I don't have any idea about what did happen on this dive, but I do know enough to rule out a bunch of ideas being bandied about in this thread.

1. This incident had nothing to do with diver preparation and training.
2. This incident had nothing to do with any psychological need to adhere to any inappropriate theoretical ideal of diving posture. She would have tried to adopt the best response to an emergency she could, as her training taught her.
3. This incident had nothing to do with a failure to respond appropriately to common problems, including especially equipment issues. She had oodles of training in the appropriate responses to such failures.
4. This incident had nothing to do with a mindset that limited her options. She had no such mindset.
 
I don't think Lynne's tragedy had anything to do with her training/skills, or equipment failure.
Based on everything I've read, my gut tells me that she had some sort of brain aneurysm or stroke or cerebral hemorrhage or something similar that incapacitated her within seconds. She was just too skilled to not get herself out of the situation if she was at all capable.
From Peters description of the accident that's all I can conclude.
Like Bob said, she was 61. There are many little physical quirks that can creep up and go completely undiagnosed sometimes for life, but they are there, and all it takes is for one very physically stressful thing to push a person over the threshold and have one of those weak spots give way and that's it.
The scary part is sometimes there's no warning signs or any tests that can diagnose such things.
 
Her fall during riding was described as a "nasty" fall and it appears it happened just days before her dive. I was just wondering if she had gone to a doctor to have things checked out. Now I know she was a doctor but sometimes as the saying goes, "A doctor can be their own worst patient."
 


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Mishap analysis & "Blamestorming"
Accident analysis is the business of identifying mishap causes and recommending actions to prevent a repeat mishap.
Who's to blame doesn't matter.
The laying of blame, extraction of justice, punishment, liability, etc - all these are the business of the courts (and to satisfy our inner need for balance and justice in the universe), but they don't really address mishap prevention. Mishap prevention involves actions.
Example:
Lets say the causes of a mishap are all actions taken by a boat's captain.
Mishap analysis would identify those actions as causes, and recommend other actions that would prevent (or greatly reduce the chance of) the mishap in the future. Nothing about liability, fault, blame, punishment etc would be addressed in the mishap analysis because those are not actions that would prevent the mishap.
Example: "The boat didn't have enough fuel on board to conduct a search." might be identified as a cause of a mishap, and mishap analysis would recommend "that a boat always carry enough fuel to conduct a search" on every dive. Why the boat didn't have enough fuel, who made the decision to carry too little fuel, whose fault it is that the boat had too little fuel, etc, are all questions for regulators and courts, not mishap analysis. And it may be that there's no blame anyway - it could be that a new standard needs to be set because this mishap revealed a flaw in the current standard.
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Mishap analysis doesn't waste time asking "what was he thinking?" either, but rather asks "what did he do?" We can agonize all day long about why Joe didn't ditch his weights when ditching his weights would have saved him, but it doesn't really matter. The action that will prevent a repeat of Joe's mishap is "ditch weights."
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What we're trying to do in the A&I forum is to provide a forum for a Safety type analysis of mishaps; to identify actions that lead to mishaps and actions that can prevent mishaps. The mishap analysis mindset is difficult for those who lack formal training in it, as our natural tendencies are to find out who or what to blame and seek justice.
Just remember that justice isn't going to prevent future mishaps. It is changes in behavior that prevents recurrence of mishaps.

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