Some Thoughts on Cave Diving Fatalities

[BgDadddy]

A couple of thoughts and questions about the tragedies that occur all too often in our community.. I posted a similar thread in the spring, but I would like to discuss it a bit further.

Whenever there is a fatality among our ranks, we always hear about it immediately and there is usually a memorial type message post put up here, as well as on the other tech diving boards. Shortly after the memorial is put up, people begin to ask what happened, and then the speculation begins.

Once that happens, friends of the deceased angrily demand that out of respect for their friend, we please avoid speculation until the investigation is complete and the facts and the cause of the accident are released to the public, or at least the cave diving community.

The problem is, this almost never happens. After the memorial thread winds down and people stop talking about the accident, we generally do not hear anything else about it. Although the IUCRR sometimes publishes general information about the recovery, it is not usually sufficient data for someone to read and make an educated determination about what happened.

All of us were taught in our very first cavern / cave diving class that we learned the do's and don'ts from analyzing accidents, however there really is no formal venue for doing so.

This year has seen a terribly high number of fatal accidents in our community. While I seem to recall there being a lot more accidents in 2007, I have come across the names of four cave dives who perished in our caves this year, and the cause of death in three of those cases has yet to be made available to cave diving community:

Ron Simmons - Although we will never know "why" the accident occurred, we do know "how" it happened, he ran out of gas approximately 300' from the entrance.

Dean Barnhart - Dean passed away way back in Madison. While it is rumored that the cause of death was a medical condition, possibly a heart attack, no one has said for sure.

Liz Halbach - Liz passed away in a cave called "The Crack" (which I have never been to). We received a lot of details and information from her husband, who was with her at the time of the accident (and my heart goes out to him), but if it wasn't for him we would know next to nothing about what happened. As it is, she appeared to have suffered from an O2 hit, and well within the generally acceptable ppo2 limits, but no one knows for sure.

Jeff Thompson - Jeff recently passed away at Ginnie in a section that probably 90% of us have been to numerous times. All signs indicate that Jeff also received an O2 hit, but again, he was well within the acceptable ppo2 limits for his gas and the depth of the cave (it is in the 90' range there and I'm sure he was breathing 32%).

Without some sort of an analysis of what happened in three of the four fatalities, how will we ever know what to do to prevent them from happening to someone else? Do we need to start diving 28% instead of 32% in our 100' caves? Who knows?

For the most part, our community is made up of some highly educated individuals. We have physicians, scientists, engineers, etc... What is stopping us from somehow getting together and reviewing these accidents in the hopes of learning from them and possibly preventing them from happening again? There are numerous avenues we could take to acquire the official findings of the police investigation and the autopsies (FOIA or something similar maybe)

Whether we did it in the form of a "private" section of the forum here and then published our opinions or maybe had a closed door face-to-face meeting a couple of times a year, there needs to be a way we can learn from these accidents.

Although I am not a doctor or a scientist, I am pretty good at analyzing data and preparing reports and I would be glad to volunteer to help out with any committee that we can form for this purpose.

Any thoughts?

Rick Hartman

[Daedalus]

I have been thinking the same thing, thanks for posting this.

[Ken Hill]

Rick,
The IUCRR has at its sole mission the responsibility to assist law enforcement or public safety agencies recover or rescue victims of an underwater cave incident.

The IUCRR report is designed to provide law enforcement authorities the who, what, where, when, why and how (if we know how) of the incident. IUCRR policies do not allow us to speculate but require us to prepare an objective report. These reports remain the property on law enforcement for their sole use in determining a cause of injury or death.

http://www.iucrr.org/p_whoweare.htm

It is our objectivity that gives us credibility with law enforcement officials. We serve at their discretion as their eyes and ears and make no findings nor conclusion. In the event we are asked by law enforcement to speculate, based on the findings at the scene we do so. Later, Medical Examiner inquiry becomes part of the investigation and not available for release except to the next of kin and the investigators assigned to the case.

Hope this helps and I appreciate your concern. We all need to keep accident analysis in our dive plans. /Ken

[RN]

Rick, great idea. It does seem that accident analysis doesn't really occur, at least not the way it should. With the exception of Liz's incident (thanks to her husband), we really don't know much about any of these deaths. Some of us may know more than others because of the circles we're in, but even that information isn't always accurate. I'd also like to see something more formal in place. I'm also willing to volunteer and contribute my knowledge and background.

[BgDadddy]

Ken,

I'm not knocking the IUCRR, you guys have your job to do and you do it well. I'm just suggesting that we put another system together to take up where the IUCRR's job ends.

This would not be for the law enforcement community; this would be for cave divers to learn from and hopefully to prevent more tragedies.

Rick

[Ken Hill]

Rick,
Understood, but there are many who have a misconception of the IUCRR mission.

One thing you may want to be assured about is that informally, the IUCRR, has as its Instructors, the Training Directors of the NACD and the CDS. They see the reports and in some cses prepare them.

Hypothetically, if there is something that needs to be addressed in training they do what they need to do. To date, if a diver plans a dive with the rules of accident analysis in mind, it should be a safe dive.

The recent cases seem to point to improperly observing the Po2's, O2 clock and OTU's. Gas mixes are necessary to include with your dive plan. O2 incidents can and have happened in open water at depths as shallow as 60fsw over the course of days of diving. I personaly don't dive PO2's greater than 1.2 .

/Ken

Health issues can strike any time and its no ones business except for the family and close friends of the victim.

[Daedalus]

Correct me if I am wrong, but it seems than in 3 of the 4 full cave divers that have perished this year they all followed the TGADL rules that we all get hammered home in our cave classes.

These 3 cases seem to be medical/tox issues and unless my information is incorrect, in at least two of the cases (Halbach, Thompson) they occurred a couple days into multiple dives per day cave diving vacations. Are these divers overlooking the previous day's OTUs when they do these dives? Should we be discouraging people from going on "dive binges" where they run multiple back to back dives working at >1.0 PO2? Should, as Rick suggests, the standard "Cave Country mix" be changed to 28%? 30%?

The amount of mystery that surrounds these cases is what troubles me the most and if there are lessons to be learned they need to be presented to the cave diving public sooner rather than later. Waiting for information to trickle down from training director to training standards to instructors to the community at large is too slow. My 2 PSI.

[Randy Thornton]

I don't mean to step on any toes here, so please don't take this the wrong way. It seems to me that it is somewhat counterproductive for the training agencies to sit on or decide which information is released to the public and which is not. As has been previously menioned, saftey issues for cave diving have been traditionally learned through accident analysis. Shouldn't all of the information be made available to the cave diving community, so that we can draw our own conclusions as to what is important and what is not? It seems to me that if just a hand full of individuals determine the information flow based upon their own biases or perception, we run the risk of the accident analysis not being made available to the people that most can use it. Just my $.02

Regards,
Randy

[DogDiver]

Ok, so why are there only 2 of the 6 fatalities listed in thier report?

[stairman]

I agree that the info is lax.I think all cave related deaths should be made public with all the details that are known.I logged onto the IUCRR website when I started my training and was dissapointed in the info that was given.Over 300 deaths and they had less than a dozen to read about.