Πάντα το ίδιο λάθος;

[Dimitris Galon]

Μετά τον θάνατο του Carl Spencer το 2009 - ο οποίος προκλήθηκε από αλλαγή σε λάθος αέριο με αποτέλεσμα η τοξική δράση του Ο2, κάτω από τις συγκεκριμένες συνθήκες πίεσης, να οδηγήσει τον δύτη σε σπασμούς και στην συνέχεια στον πνιγμό - ένας νέος θάνατος, οφειλόμενος στο ίδιο γεγονός, έρχεται να υπογραμμίσει την πολύ ευαίσθητη, σημαντική, και απόλυτα ζωτική δεξιότητα της αλλαγής των φιαλών αγκίστρωσης που περιέχουν καταδυτικά αέρια.

Ο βετεράνος δύτης του WKPP (Woodville Karst Plain Project) Jim Miller, απεβίωσε το προηγούμενο Σάββατο, 11 Ιουνίου 2011, μετά από πνιγμό που προήλθε από τοξικό σοκ και σπασμούς λόγω της αλλαγής σε λάθος φιάλη αγκίστρωσης αναπνευστικού αερίου.

Ακολουθεί αναφορά στο γεγονός από τον Todd Leonard, φίλο του αποβιώσαντα και έναν από τους διευθύνοντες του WKPP.

Hello, all...

I'm Todd Leonard, one of the Project Coordinators for the WKPP, and one of Jim's friends.

I posted info in the accident analysis thread on the Cave Diver's Forum about Jim's accident Saturday, and it seemed to be helpful there in minimizing the speculation that we often see when trying to make sense of the loss of someone from our community. It wasn't practical to follow threads on all forums in real time, but I'm hoping that posting a summary here now may be valuable.

If at all possible, I'd like to request a moderator correct the thread title. Jim did not die while diving from Wakulla, but from Whiskey Still Sink. Whiskey Still is distantly connected to Wakulla in that it's part of the Leon Sinks chain, and of course the systems have been connected, but to most people the name Wakulla will be interpreted as a reference to the well-known entrance within the park, so it's misleading.

My initial posting was...

Quote:

I'm very sorry to report to you that our friend and fellow explorer Jim Miller died today during a dive in the WKP.

It's too early for us to report on the dive in great detail, but what I can tell you is that he seized and drowned in the cave after breathing a 70ft deco bottle for an extended period of time on his way into the cave. The bottle was marked and analyzed correctly. The depth was approximately 200ft and the incident occurred soon after the team turned and began their exit. He was brought back to the basin by his buddies following an unsuccessful attempt to revive him at depth, and then to the surface by other team members.

I posted more as I received additional detail, and as I received questions from CDF members who were wondering various things. Rather than trying to assemble and repost all that, however, I think I'll just try to present a chronological summary of the dive:

Jim was diving with two buddies Saturday, each using an RB80 rebreather. They entered at a site in the WKP (Woodville Karst Plain) called Whiskey Still Sink. From Whiskey, the conduit proceeds at a shallow depth to Innisfree Sink, and beyond Innisfree it drops deeper to a max depth around 220ft and continues. Thus, their decompression was to be done on the other side of Innisfree. Their bottom mix was 240 gas. They carried deco gas to be used at 120, 70, and oxygen at 20. Given the offset profile, they did their own deco setup.

They began the dive on their 120 bottles, which are suitable for the shallow cave between Whiskey and Innisfree. Passing Innisfree they dropped deco bottles at their respective depths. The first error occurred at the 70ft stop, where Jim dropped one of his 240 bottles -- he should have dropped his 70ft bottle, and it should not have been carried any further into the cave.

After proceeding down to the 120ft stop, the team stopped for their switch to 240 gas (their bottom gas). At this point the second and most serious error occurred -- Jim switched onto his 70 bottle. Part of our standard procedure and a very critical step in each and every bottle switch is to check the MOD sticker on the side of the bottle, which would have made very clear that he was about to switch to the wrong bottle; we don't know why, but this check was missed. We also want buddies to watch each others' switches carefully enough to confirm the correct bottle is in play, but this secondary check was not performed and the error was not caught. Following the switch the team dropped their 120 bottles, and proceeded into the cave.

They continued into the cave for a little less than an hour (with Jim breathing his 70 bottle), and turned the dive as planned. Not long after the turn, Jim experienced a seizure. His buddies tried unsuccessfully to help him recover from the seizure, and Jim drowned.

After a prolonged exit the team was able to bring Jim back to the basin at Innisfree, and shortly thereafter a pair of our support divers brought him back to the surface.

So, that's the crux of it. There was a significant error, a critical error, plus missed opportunities to catch and correct those errors.

Jim was a very experienced and responsible diver, and known among his friends for his exceptional meticulousness. We're profoundly shocked and saddened to lose him, and he'd be one of the last people we'd ever imagine might die this way. This dive was well within his skill and experience levels, and the site was very familiar to him.

- Todd Leonard

Για περισσότερες πληροφορίες και ανταλλαγές απόψεων ακολουθήστε τον σύνδεσμο των DIR-Explorers.

[Thanos]

Good Morning
The past 40+ hours have been difficult for the family and the dive team. Todd Leonard has been communicating basic information as it becomes available. In reading some of the responses, I must agree: Jim was a well respected member of the cave diving community, joined the WKPP as a support diver in 2002, became a senior team explorer doing serious setup and exploration dives, completed a 12,000ft setup in Wakulla only a few weeks ago, will not be easy to replace in or out of the water, appears to have skipped several basic gas checks with fatal consequences. Jim was recently promoted by the US Army to Full Colonel and had a reputation within the team of being meticulous, detail oriented and by the book. This makes the entire situation difficult to understand but based on the information we have, this is what appears to have happened. No excuses to offer other than to strongly suggest to everyone in the cave and tech diving community to double check the basics and talk among your dive team members. Of course there is a secondary buddy check procedure and it appears that was missed but in the end, the diver owns the responsibility to check his/her breathing gas, especially at this level with multiple mixes in the water. I saw a comment about narcosis being obvious with the 50% mix. We are reasonably certain that Jim was using a 50% O2 and 50% HE deco mix. This is not unusual as team members reserve the right to add HE to any mix and the analysis tape on the tank indicates this. I cannot confirm because the authorities impounded the equipment but we will eventually confirm. Yes, had the diver or team caught the error in dropping the wrong tank at 70ft in the first place the outcome may have been different but ultimately the diver must verify every breathing mix before he breathes it or plugs it into the RB. If more information becomes available I will ask Todd to communicate to the list but I believe it is exactly what it looks like and based on interviews Jim was relaxed and looking forward to the dive that morning. Jim will be missed.

Safe Diving,
Casey McKinlay
Project Director
Woodville Karst Plain Project

Κρίμα....

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