(This dive report was reprinted by permission of Robert Kinder and is in the public domain. This report was rendered anonymous by the request of Mr. Kinder)
DIVE ACCIDENT REPORT
OCONEE COUNTY RESCUE SQUADS
OCONEE COUNTY EPA OFFICE
WALHALLA, SC. 29691
(864) 638-4200
INVESTIGATOR: ROBERT A. KINDER
PADI MSDT-63946
IAND TRI-MIX 6-1992
SUBMARINER RESEARCH TRI-MIX 1991, CERT# 6
ASSOCIATION OF DIVING CONTRACTORS, COMMERCIAL DIVER, CERT# 24
INCIDENT LOCATION:
LAKE JOCASSEE (NEAR THE WALL)
SALEM,SC
05-01-1999
TIME OF INCIDENT: 14:10
EMERGENCY RESPONSE CALL: 14:12
VICTIMS NAME:
MALE DIVER 1
DAYTONA BEACH, FL
WITNESS:
MALE DIVER 1
FEMALE NON DIVER
WAYNESVILLE, NC.
MALE DIVER 2
ASHEVILLE, NC.
MALE DIVER 3
ADDRESS UNKNOWN
DIVE PLAN:
ON 05-02-1999 MALE DIVER 1 PLANED A 325 FOOT DIVE IN LAKE JOCASSEE, PRIMARY PURPOSE OF THIS DIVE WAS TO TEST A NEW LIGHT AND TEST OTHER EQUIPMENT. DIVE WAS TO BE SOLO.
PLANNED DIVE PROFILE WAS AS FOLLOWS.
THE FOLLOWING WAS COPIED FROM MALE DIVER 1 'S WRIST SLATE.
S- E- AIR-200
^_ >- EAN32-130
B- D- EAN50-70
BT- RT- EAN80-30
5 10 15 5 10 15
110 2 2
100 1 2 3
90 1 1 2 2
80 2 2 1 2 4
70 1 1 3 1 2 3
60 1 3 3 1 2 4
50 2 3 6 2 4 6
40 2 5 7 3 5 8
30 4 7 9 4 8 11
20 6 10 15 7 12 17
10 24 39 56 25 43 65
THE ABOVE IS EXACT NO OTHER NOTATIONS OR MARKS, THE LEFT SIDE WAS WITH ALL GASSES THE RIGHT SIDE WAS FOR LOSS OF ONE GAS.
NARRATION:
MALE DIVER 1 'S COMPANIONS WHERE TO MAKE A DEEP AIR DIVE TO 190 FEET AS A TEAM DURING THE SAME TIME AS MALE DIVER 1 WAS MAKING HIS TRIMIX DIVE. BOTH TEAMS LEFT THE SURFACE ON OR ABOUT THE SAME TIME. FEMALE NON DIVER REMAINED ON THE BOAT. (FEMALE NON DIVER IS A NOW SWIMMER).
MALE DIVER 1 'S DIVE STARTED AS PLANNED, HOWEVER, AT 175 FEET HE FOUND A LINE TANGLE, HE ATTACHED HIS CAVE REEL AT 175 FEET AND CONTINUED DOWN. HE STATES THAT AT 275 FEET HE FOUND HIMSELF TANGLED IN A LINE OF SOME FORM. MALE DIVER 1 AT THIS POINT HAD CONSUMED 950 PSI OF HIS BOTTOM MIX (1800 PSI REMAINING) ONCE FREE HE CONTINUED ON DOWN. AT 305 FEET HE AGAIN WAS TANGLED IN A LINE, HE ONCE AGAIN CUT THE LINE CAUSING HIS ENTANGLEMENT. DURING THIS SAME TIME HE CUT THE GUIDE LINE RETURNING TO THE SURFACE. WHILE FREEING HIMSELF HE STIRRED UP THE SILT AND LOST THE LINE. BEING UNFAMILIAR WITH THE BOTTOM CONTOUR MALE DIVER 1 DECIDED TO MAKE AN OPEN WATER ACCENT. SHORTLY AFTER BEGINNING HIS ACCENT HE NOTED HIS TANK PRESSURE TO BE 400 PSI. AT 200 FEET HE WAS TO GO ON AIR AS A TRAVEL GAS THIS WAS NOT DONE. UPON REACHING 130 FEET HE SWITCHED TO EAN-32 FOR STAGED DECOMPRESSION. MALE DIVER 1 HAD TROUBLE OBTAINING BUOYANCY CONTROL, AT THIS POINT HE REALIZED THAT THE BOTTOM MIX HAD REACHED 0 PSI. AND COULD NO LONGER INFLATE HIS BCD. HE COMPLETED HIS 130 FOOT STOP AND ASCENDED TO 120 FEET PLANING TO USE HIS DRY SUITE FOR POSITIVE BUOYANCY. HE COMPLETED HIS 120 FOOT STOP AND ASCENDED TO 110 FEET AT THIS POINT HE REALIZED THAT HE WAS POSITIVE, AND THAT HIS DRY SUITE VALVE WAS NOT VENTING PROPERLY. MALE DIVER 1 MAY HAVE COMPLETED HIS 110 FOOT STOP, AT THIS POINT HE DECIDED AGAINST LETTING AIR OUT OF HIS BCD FEARING THAT HE WOULD BE UNABLE TO OBTAIN SUFFICIENT BUOYANCY TO REACH THE SURFACE AND DECIDED TO SKIP THE REMAINDER OF HIS DECOMPRESSION FROM 100 FEET UP. UPON REACHING THE SURFACE HIS TOTAL UNDER WATER TIME WAS 39 MIN. MALE DIVER 1 SURFACED 75 TO 100 FEET FROM THE BOAT AND MANAGED TO SWIM TO THE BOAT. HEALSO, MANAGED TO REMOVE HIS FINNS AND HIS EAN-50 TANK. TIME ON SURFACE 3 TO 5 MIN. HIS HANDS BECAME NUMB AND FEMALE NON DIVER CUT HIS EQUIPMENT OFF AND PULLED HIM ONTO THE VESSEL. BY THIS POINT PARALYSIS WAS PRESENT FROM MID CHEST DOWN. SHE CALLED FOR EMS HELP AND BEGAN TRANSPORT TO THE MAIN LANDING, DURING THIS TRANSPORT THE BOAT RAN OUT OF FUEL. A PASSER BY PLACED THE BOAT IN TOW, BOTH BOATS WERE MET BY RESCUE PERSONNEL AND ALS WAS STARTED THIS INCLUDED HIGH FLOW 02 AND IV FLUIDS. VICTIM RESPONDED WELL TO FIELD TREATMENT AND REGAINED USE OF LEGS AND PARTIAL USE OF ARMS. MALE DIVER 1 WAS EVACUATED BY AIR FROM THE MAIN LANDING TO THE RECOMPRESSION CHAMBER AT PARK RIDGE HOSPITAL IN FLETCHER, NC.
INITIAL MEDICAL EVALUATION AND FIELD TREATMENT:
PT. WAS IN A PRONE POSITION ON THE DECK OF A PONTOON BOAT, HE WAS ALERT AS TO TIME PLACE AND EVENTS, RESPONSES WHERE SLOW, PT. HAD SOME IMPAIRMENT. RESPIRATIONS 28/ MIN. PULSE 110 BRACHIAL, RADIAL PULSES FAINT. BP WAS 80 / PALP. PT. HAD NO CONTROL OF ARMS OR LEGS, SKIN WAS COLD AND CLAMMY, WITH A MOTTLED APPEARANCE. PUPILS EQUAL CONSTRICTED TO 3MM NOT RESPONSIVE.
TO THIS POINT PT. HAD RECEIVED NO MEDICAL ASSISTANCE.
FIELD TREATMENT CONSISTED OF HIGH FLOW 02, VIA. NONREBREATHING MASK, BILATERAL LARGE BORE IV'S NORMAL SALINE. AFTER FIRST 500 CC. BP HAD INCREASED TO 90 SYSTOLIC. AN ADDITIONAL 500 CC WAS ADMINISTERED AND BP WAS THEN RECORDED AT 126 SYSTOLIC. LUNGS CLEAR AND EQUAL. SA02 WAS 100 PERCENT. CARDIAC MONITOR INITIALLY SHOWED SINUS TAC., AFTER RETURN OF NORMAL SYSTOLIC PRESSURE RATE WAS 80 SINUS RHYTHM WITH NO ECTOPY. BGL WAS 106. BETWEEN 15 AND 20 MIN. INTO TREATMENT PT. WAS ABLE TO PUSH AND PULL WITH HIS LEGS AND DETERMINE SHARP / DULL IN ALL EXTREMITIES. PT. WAS LESS CONFUSED AND SKIN COLOR WAS MORE NORMAL. CARE WAS TURNED OVER TO THE MISSION ST. JOSEPH'S FLIGHT CREW FOR TRANSPORT TO THE DAN ASSIGNED RECOMPRESSION CHAMBER AT SPARTANBURG REGIONAL HOSPITAL. THE CREW HOWEVER, DIVERTED TO FLETCHER, NC. DUE TO DECREASED FLIGHT TIME. FOLLOWING RECOMPRESSION THERAPY PT. WAS MUCH IMPROVED PER MR. MALE DIVER 1 .
EQUIPMENT EXAMINATION:
PRIMARY IMPRESSION WAS THAT ALL EQUIPMENT WAS WELL CARED FOR HIGH QUALITY AND HAD THE APPEARANCE OF BEING IN LIKE NEW CONDITION.
THERMAL DRY SUITE WITH THERMAL UNDERWEAR SUFFICIENT FOR THIS WATER TEMP.
BCD WINGS, WITH STANDARD BACK PLATE AND HARNESS, LEFT STRAP CUT DURING RESCUE. 13 CUF TANK ATTACHED TO FRONT OF HARNESS WITH INFLATOR HOSE CUT. TANK NOT LABELED. SCUBA PRO FIRST STAGE WITH R-190 SECOND STAGE. (LATER LEARNED THIS WAS FOR DRY SUITE INFLATION AND FOR AIR TRAVEL GAS ABOVE 200 FEET.)
BOTTOM MIX 120 CUF STEEL TANKS IN HYDRO. DUAL MANIFOLD WITH 02-12% ISOLATOR BAR. STARTING PRESSURE OF 2750. PRESSURE HE-47% AT TIME OF EXAMINATION 150 PSI. REGULATORS N2-41 % ATTACHED SCUBA PRO MARK 15 FIRST STAGE'S WITH G-250 SECOND STAGES, SHORT HOSE USED AS SAFETY SECOND PRIMARY WAS LONG HOSE VENTURI SET TO MAX.
NO EXTERNAL SIGNS OF FAILURE NOTED.
EAN-32 32 CUF RIGGED AS A BACK MOUNT PONY BOTTLE, REGULATOR MARK 15 FIRST STAGE WITH R-190 SECOND STAGE. TANK VALVE FULL ON. STARTING PRESSURE 2700 ENDING PRESSURE 1000 PSI. SECOND STAGE RIGGED FOR LEFT SIDE BREATHING.
EAN-50 32 CUF RIGGED AS STAGE BOTTLE, LEFT SIDE FRONT. TANK VALVE FULL ON. REGULATOR FULL ON. STARTING PRESSURE 2700 ENDING PRESSURE 2300 PSI.
REGULATOR MARK 15 FIRST STAGE WITH R-190 SECOND STAGE. SECOND STAGE RIGGED FOR LEFT SIDE BREATHING.
EAN-80 32 CUF RIGGED AS STAGE BOTTLE, RIGHT SIDE FRONT. TANK VALVE FULL ON. REGULATOR FULL ON. STARTING PRESSURE 2700 ENDING PRESSURE 2700 PSI. REGULATOR MARK 15 FIRST STAGE WITH R-190 SECOND STAGE. SECOND STAGE RIGGED FOR RIGHT SIDE BREATHING.
OTHER EQUIPMENT:
DIVER TRAINING:
CONCLUSIONS:
VICTIM WAS ATTEMPTING A DIVE THAT WAS BEYOND HIS EXPERIENCE LEVEL, HIS LACK OF PROPER SUPPORT PERSONNEL AND A DIVE PARTNER SHOULD BE CONSIDERED AS CONTRIBUTING FACTORS TO THIS INCIDENT. WHILE HE WAS PROPERLY EQUIPPED TO DEAL WITH ALL OF THE PROBLEMS ENCOUNTERED ON THIS DIVE. THE DIVER FAILED TO USE ALL OF HIS OPTIONS, THIS INCLUDES THE FAILURE TO DEPLOY AN UP LINE WITH HIS LIFT BAG AND SECOND CAVE REEL. THE FAILURE TO OBTAIN PROPER BUOYANCY CONTROL VIA HIS BCD. FAILURE TO DEAL WITH HIS DRY SUIT DUMP VALVE'S FAILURE TO EXHAUST BY USING OTHER COMMON VENT POINTS (NECK AND WRIST SEALS). FAILURE TO RECOGNIZE THAT HIS BCD'S ORAL INFLATOR WAS USABLE EVEN AT DEPTH. FAILURE TO USE HIS DRY SUIT INFLATOR HOSE FOR CONTROLLING HIS POWER INFLATOR AFTER EXHAUSTING HIS PRIMARY INFLATION SOURCE. FINALLY THE DIVER IN THIS INCIDENT MADE A DECISION TO ACCEPT A POSSIBLE DCS INCIDENT BY NOT COMPLETING DECOMPRESSION. REASON BEING HE WAS CONVINCED THAT HE COULD DROWN.
CONTRIBUTING EQUIPMENT CONSIDERATIONS:
NON CONTRIBUTING EQUIPMENT CONSIDERATIONS: