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

[Nitrogenius]

Long jumps are not an issue as long as you do proper an convervative gas planing. You guys are not looking for the root cause. That's not how you do accident analysis. When a driver hits a tree next to the road while intoxicated and speeding, the solution/lesson is not to cut all down trees close to roadways (even though the tree killed the driver). The solution/lesson is: dont drink and drive and dont speed. You always need look for what started the series of events not what ended it. Making jumps shorter is a bandaid.

Oceancurrent, arent you a pilot? In plane accidents they also look for the root cause, dont they?

you are right in your example bent, the trees are not the root cause, however it still makes sense to cut the trees to reduce risk, not only drunk and fast driving can lead to cars crashing in the trees and to stay in the comparison not all situations a diver runs low on gas close to an unmarked exit or a long jump must relate to some rule breaking. Best example is in fact that student that was left in the cave by her instructor. At least she did not break any rules and could not have planned for this etc. and if in fact these exits would have been marked she would be alive today.

Yes long jumps are not an issue per se and can be managed..
Again one should ask why is a superlong jump as the one from Paso de Lagarto necessary in the first place?
or why is the gap at Ho-Tul so extremely long?
There is not even any plausible reason.. Psao de Lagarto is not particularily more pristine as staying on the main line in that area.. ok staying on the main line takes you to tha super long gap of Ho Tul as I remeber, but again are those to keep divers out of Paso de lagarto or out of Cuzan Nah loop? Makes no sense to me as there is a giant map right at Gran Cenote and it is obvious that the cave goes so if you want to go you search and find eventually..
No gain wahtsoever in comparison to a somehwat "regular" Jump distance or gap distance..
At Paso if you wanted to keep folks out you likely could bring the line pretty close to the main line and still have it somewhat shielded from vision from the mainline, while you would clearly see the mainline when coming from Paso if it was closer..
The latter (main line not visible) was the cause of the fatalities at the "initial" Kalimba accident, if the main line would have been visible at EOL coming from calimba towards Gran Cenote those divers would likely still be alive. The line towards Box Chen and Kalimba has changed as a result of that accident (proper Jumps where isntalled instead of this stupid gap line or whatever it was called) but the distance between Paso and Gran Cenote line was never fixed, which I never understood..

So as to your example Bent, yes the long Jump at EOL in Paso was not the root cause at that "initial" Kalimba accident but if the jump was longer still the divers would be alive and what is the long jump worth to begin with.. Trees in the example would have more reason to be there than there is any reason to have that Jump that long

[Nitrogenius]

I see. So in the case of the student whose instructor separated from her and pulled all the jumps so that she could not find her way out, her poor planning started with...well, what exactly?

As for the two Germans, we don't know what went wrong in their dive, leading them to change their plan and seek an exit that had a big gap in the exit line.

All we know is that in both cases, dives did not go according to plan and divers died in an unmarked area frustratingly close to an exit.

Exactly!!

[Nitrogenius]

Yes. And, while filming was mentioned here and there, it appears (speculation, but more reasonable I guess) that one of them violated thirds. Blaming that on filming is a reach. Had they gotten back to their stages, they would have had ample gas since they dilly dallied on the swim in. What took them 29 mins on the way in, should take 1/2 that on the way out. They got lost. They had a gas failure. They made poor decisions all around. But the fact that the camera is somehow "singled out" to some extent, to me, is a stretch and very, very speculative.


We don't know what caused them to make the poor decisions they appear to have made, so it's obviously not plane and simple that the camera and filming was actually a contributing factor. It's just what someone speculated. The only plane and simple part is that they didn't get to their stages, and most likely didn't plan correctly, or execute the plan they had correctly.


We all have inherent biases. Nothing to do with plot twists or watching too much TV. It has to do with people stating stuff like it's factual or relevant, and others perpetuating that because they want it to be true, even though there is nothing factual (nobody knows that the camera was a contributing factor) about it. And nobody can be sure it was even relevant. That's all I'm saying. Downplaying our biases that can cause us to be wrong is dangerous and inhibits us from getting good, factual reports. Otherwise, they are just stories that people believe, not a statement of facts.

I do think that healthy discussions on possible causes, and what could be done if that a particular scenario was the root cause, are helpful. But treating them like they are anything more than "what if" scenarios is not good in my opinion. Facts are facts. Everything else is not.

I will say the people who did put that report together did a phenomenal job, and I thank them for their hard work. And even they tend to indicate where stuff is speculative, but there could also be other stuff that either they missed, or their speculation could be completely wrong. But since it was wrapped in a thorough, very well-put-together report, people treat speculation more as fact. And I'm guessing that is also not what those who wrote the report want.

Stay safe.

Chris

Absolutely right and even the violation of thirds is a speculation as well is the filming aspect as root casue (of course filming has been involved no doubt)
And having seen footage, depth profiles, time indicies, profiles, having received survey data on depth profiles and structures after the incident etc etc.
There is several areas where the assumptions on which the report was based on was wrong, but it is really extremely hard to tell.
And yes respect to the reporting team. They might have it right, but it also could be several other explanations possible given the data. Especially there is question marks to the actual route that had been reconstructed.
Point is we will never know what really went down!

[bent]

you are right in your example bent, the trees are not the root cause, however it still makes sense to cut the trees to reduce risk, not only drunk and fast driving can lead to cars crashing in the trees and to stay in the comparison not all situations a diver runs low on gas close to an unmarked exit or a long jump must relate to some rule breaking.

If you follow that logic it leads to closing the cave. The point in the example was that you cannot make a activity fool-proof. Cutting down every tree and changing every line is not an realistic option. Teaching people that being distracted is really, really dangerous and bringing an extra bunch of gas is a good idea, is realistic.

Absolutely right and even the violation of thirds is a speculation as well is the filming aspect as root casue (of course filming has been involved no doubt)

If it wasn't the filming and ultimately turning to late, what else would have made them swim a weird path and made them end up with empty tanks in swallow water?
You can call it speculation but it's based upon evidence.

They might have it right, but it also could be several other explanations possible given the data.

What are the several other explanation?

[Nitrogenius]

If you follow that logic it leads to closing the cave. The point in the example was that you cannot make a activity fool-proof. Cutting down every tree and changing every line is not an realistic option. Teaching people that being distracted is really, really dangerous and bringing an extra bunch of gas is a good idea, is realistic.

I was just using your example.. I disagree that it would lead to closing cave.. Staying in the comparison closing caves would equal banning cars or not building roads anymore..
It is not a black and wide topic. But again staying in your example also authorities do in fact cut trees becasue of that topic and new roads are never ever planned to plant trees next to them..
best practise evolves.
So if there is really no compelling reason for not marking a particular exit, or no compelling reason to have a super long gap or jump. Why doing so..
If there is a reason then it should be balanced against potential negative impact.
Adressing issues at the root is obsiously the best option, but one does not exclude the other.. You can do both and why not doing both? So better training but also minimize unecessary "line risk"
In that particular cave and that area it is obvious that several lifes could have been saved with marginal measures and adjustments totally independent from their respective root cause.. That is the point I am trying to make

If it wasn't the filming and ultimately turning to late, what else would have made them swim a weird path and made them end up with empty tanks in swallow water?

How do you know for a fact that they were in fact swimming a weird path?
who can say for certain that most of the inscriptions that were found on the wetnotes were unrelated and from a different dive?

What are the several other explanation?

There will be no benefit to discuss these here in the forum other than potentially create new scars and stir up other issues.
Maybe if we ever get the chance we can have a conversation about it. All I am willing to say is that I have been in long and intensive contact with the widow of one of the deceased.

[bent]

You talk about accidents in order to come up with a lesson to make diving safer in the future. If you guys just wanna sit there and repeat that 'we dont know', the whole discussion is pointless. I have drawn a lesson from this, If you haven't it's your loss.

There will be no benefit to discuss these here in the forum other than potentially create new scars and stir up other issues.

Of course there is a benefit in discussing accidents and of course these discussion are not meant to be read the familiy of the victim. I thought that's obvious.

[Nitrogenius]

You talk about accidents in order to come up with a lesson to make diving safer in the future. If you guys just wanna sit there and repeat that 'we dont know', the whole discussion is pointless. I have drawn a lesson from this, If you haven't it's your loss.

It is not about repeating "we don't know"
Some stuff is known.. It is just not enough to be certain that what the report illustrates is what actually happened. That is all I am saying.
You draw a concludion based on the report.
That is ok to do..
But it is not better than drawing conclusions from other potential scenarios or any individual dive plan where you plan for incidents that could happen

Of course there is a benefit in discussing accidents and of course these discussion are not meant to be read the familiy of the victim. I thought that's obvious.

I am not doubting that there is benefit in dicussing accidents.
Even more if the accident report is conclusive enough.
Just in that particular case there is not much to learn from as the report is not conclusive enough so that there is a significant chance that it happened differently which would somewhat invalidate any lesson learned.
Having said that there is always benefit of planning for incidents that could in fact happen..

[mdax]

I used to care, back when I started cave diving.
Then as the years went by I realized that not one death changed the underlying cave diving rules or how I dive and now I don't care.

[oceancurrent]

97% are not satisfied with the current accident reporting and analysis system. That's an overwhelming vote of no confidence to the people in charge. Time to get serious about the overdue overhaul?

[Nitrogenius]

97% are not satisfied with the current accident reporting and analysis system. That's an overwhelming vote of no confidence to the people in charge. Time to get serious about the overdue overhaul?

I think this has been an ongoing trend for quite some time..
If people in charge would in fact care, I would think they would have taken action for quite some time.
So I do not expect anything from this.
Except that it continues to document the dissatisfaction