Want rapid accident analysis and want the IUCRR to determine a mechanism

[EBRAUN]

Here is a copy of the email sent:

Good Afternoon Richard,
It has been brought to my attention that you have released confidential information involving the recovery of a cave diver over the week. There is still an open investigations through the Gilchrist County Sheriff's Office. Once they release the information to the family and close this case the IUCRR will release an accident analysis report through our website.We respectfully request that you remove all public posts containing details of the recovery. Details obtained from only one diver and prior to official reporting to law enforcement may be incomplete or may contain information that was perceived at the moment, but later determined to be different. As you know, events like this involve multiple people, perspectives, and observations. I am sure the purpose for posting the details was to begin the accident analysis phase, however, as I'm sure you would agree, conducting an accident analysis without 100% accurate and complete information could cause more harm than good. The IUCRR is undergoing some positive changes and I hope you find our final analysis informative. We all need to learn from incidents to include how the IUCRR manages incidents and trains. Would you please share with me which diver provided you the information? This is not to shame them or call them out on it, but to allow us to focus training and encourage everyone to follow our Standard Operating Procedures. The Official statement on this recovery is as follows"

"The IUCRR was involved in a recovery of a missing diver over the week. An accident analysis report of this recovery will be released once the Gilchrist County Sheriff's Office has closed the investigation and the family of the missing diver has the final details. Until that time anything released will be false information and hearsay. Out thoughts and prayers are with the family at this time."

[WEPIV]

Nice pen-name...(nom de plume)

[bent]

... encourage everyone to follow our Standard Operating Procedures.

I'm glad Richard leaked it and I appreciate his and his source's willingnes to take the flak for it. If it wasn't for his post, hardly anyone would have heard about this accident a year later. Leaking and gossip seem to be the only way information and lessons from that information get to divers these days.

As we learned in the other thread, a bunch of instructors even think accident analysis is pointless anyways and rather keep every bit of information under wraps. I really dont get why but it seem to be the Standard Operating Procedure.

[PfcAJ]

At least there’s a functioning Rug and Broom committee within the IUCRR.

[tbone1004]

alright so now I'm curious where that report is since they clearly stated it would be released and there is no way that the case is still open.
Also curious who the 3 people so far are that voted they are happy with our current "system" and if they'll actually speak up and say why they're happy with the current "system".

Also of note, I really don't care about the accident analysis portion of the IUCRR. I honestly couldn't care less about that if that is the part they are worried about since that is opinion based. Give us the recovery facts and let us analyze on our own, nothing anyone can do to you about posting those recovery facts literally the day the body is recovered. The minute Bozanic as database manager receives that report it should be entered into the database and published. The opinions on analysis can wait, let the CDS do it at the conference, let the people do it on forums, whatever, but the recovery sheets should be posted immediately. I have experience in database creation and management and sent Jeff a note a few days ago offering directly to assist if requested since the emails sent off last year went without response.

[lord1234]

snipping a piece out of EBRAUN's post:

Once they release the information to the family and close this case the IUCRR will release an accident analysis report through our website.

Is there still an active investigation? Where is the accident analysis report? It's been nearly if not over a year. The ICURR hasn't released a report since 2019, it's been 3 years...have there been no cave fatalities in FL since that time? Are all still active investigations?

BTW: The answer to my first question could be found via a phone call to Gilchrist County Sheriff, or at most a FOIA request, so please don't say "well I can't tell you that".

[TraceMalin]

I don't know if the magazine is still around, but when I was skydiving in the 1990s our drop zone got "Chuting Star" every month. Every skydiving accident that occurred the month before was printed including the decedents' names, the facts of the accident, and expert recommendations to prevent a similar accident from happening to you. That would be great if UWS or another magazine did that.

[bent]

Can anyone who's a US citizen just make a FOIA request for accident reports? The names could be taken out and a summary could be published on a forum or in some magazin like Quest as Trace suggested. Someone posted an sample request letter a while back... sounded like it just cost a couple of bucks and a few emails. If it's that easy to get these reports why even bother with the IUCCR reports?

What I wonder is, if it could have a negative impact on cave access when reports are published more publicly rather than on a forum like this. Cave diver should have access to reports but maybe I'd be better not to have it on places like scubaboard or other places with lots of non-cave diver readers.

[bent]

Jon Bernot and I will be giving an accident analysis presentation at the NSS-CDS Conference ...

Any chance this is going to be filmed or the audio recorded? I'm sure lot's of people would like to listen or see that presentation.

[DecompressedPhoto]

2 cents from an aviation accident investigator's perspective; following standards set out in the aviation environment I work in: (all details made up for the sake of discussion)

1. A timely initial report should be issued within 24 hours that only includes factual information and 0 analysis e.g. diver found at xyz depth at xyz feet into name your cave system, primary regulator present in divers mouth, long hose regulator deployed and caught on rock, mask in place, light on, sidemount harness in use, 2x LP85 tanks - left tank 0 psi, right tank 1800psi remaining etc..... No analysis should be released. Essentially anything that is public information. As if you stumbled across the scene yourself and only purely factual information with no personally identifying details included. The entire report remains anonymous, with identities only known to the mishap investigating team. The name(s) of the mishap diver(s) will never be released by the investigating team. This is to not only protect the personal lives of those affected, but to also offer a safe haven to anyone involved to speak open and honestly about the mishap and any events leading up to it.

2. Once analysis is performed a thorough and complete accident analysis should be released. The investigators should understand the why behind every diver action and every factor leading to the event, gear malfunction etc... Example of what these reports resemble

Timeline of events starting at the beginning of the mishap day timestamps included.
0800: The mishap diver(MD) and mishap dive buddy(MDB) arrive at the mishap dive location (MDL) in the same vehicle
Insert boring stuff here:
Eventually leading to:
0853: The MD sees MDB shake his light quickly up and down which possibly blinds MD missing the MDB's upward pointing thumb of their right hand
0853: The MD deploys their long hose for MDB and likely assumed MDB was out of air
0854: The MDB swims towards the exit not seeing the MD's response leaving MD behind
0854: The MD attempts to store their long hose clipping the bungee to their harness
0854: MD does not stow the long hose evident by the drag marks in the silt leading up to where MD's body was recovered
0855: MD's long hose second stage regulator is yanked free from their harness and is caught in the rock where MD's body was recovered
0856: MD silts out their location and is out of reach from the main line evident by silt settling on top of MD's body and gear
0857: MD is unable to find the mainline or secure their regulator
0923: Estimated time of death due to drowning based on calculated SAC rate from remaining gas in the right tank and the turn location of the dive combined with dive computer data from MDB's indicating when the turn was made

Factors leading to fatality:
Causal Factor 1 - non-universal signals being taught by different training agencies/instructors leading to an unnecessary long hose deployment by MD.
Causal factor 2 - diver training agency/instructor/training standard inadequately prepares divers to handle out of air emergencies and how to store their own long hose.

Recommendations:
1 - Standardized hand and light signals across all agencies and instructors
2 - Standardize long hose stowage procedures and requirements for all cave dive training agencies
3 - Publish an educational brief on long hose stowage procedures and emphasis of dive buddy signal standardization


3.If at any time during the analysis it is determined that there is an immediate and urgent need to notify the public of a safety concern e.g. a component is prone to fail under certain conditions, or in someone's example bad gas from a dive agency, the investigating teams releases that information to the public and or appropriate parties to prevent any further loss of life or injury. Not only is the why answered, but also the how to prevent similar accidents occurring in the future- a recommendation of a corrective action.

4. A peer review by another accident investigator(s) occurs to adjust and find any missed or overlooked causes, contributing factors until all questions about the mishap are answered.

5. The peer reviewed accident analysis report is released to the diving community for the benefit of the diving community with anonymized parties, locations, involved. It is published in a location that can be accessed by the diving community freely.