The Rules Apply to All of Us


If you are a technical diver — a cave diver, a trimix diver, a rebreather diver, something of that sort – you have read someplace that complacency kills experienced divers. Fact is, you may have read it several times and heard it said repeatedly because that phrase is contained in most if not all technical diving textbooks. It is so commonly bandied about that for some of us, it may have become a little trite… a cliché… something to become complacent about.

Time to smarten up.

Recently, there was yet another senseless death, which might serve to illustrate the point. This one happened at Ginnie Springs in north Florida.

A young guy named Carlos Fonseca had an oxygen toxicity episode a couple of hundred metres inside the cave and died. He was breathing from a stage bottle clearly marked oxygen and later analysed to be just about pure O2. According to statements from the folks diving with him, Carlos thought he was breathing air.

Before the dive started, he was questioned about the bottle, challenged about analysing it, but insisted that he had filled it with air, even though it was labeled for dedicated oxygen service. Now he is dead.

This incident is sad and terribly tragic… a family without a dad/husband/son/brother et al… But unfortunately it is not surprising that a certified cave and trimix diver died doing a simple, run of the mill dive that was WELL within the scope of his training and experience. As slight as his experience may have been, and as rapidly as he had progressed from open-water diver to cave diver, the dive was a simple one for which he had adequate training.

Diving is an activity that requires some restraint because it is so easy to push beyond one’s capabilities… as Steve Berman once said — and I paraphrase — any twerp can get to the back of a cave. But not everyone can manage the journey back out.

I did not know Carlos… never even met him… but I do know the fella who taught him to cave dive and a couple of buddies had dived with him during the past couple of years. He had progressed from open-water punter to trimix and cave in a couple of years. He had the money, time and desire to do so.

The over-arching assessment from the people I know who knew Carlos was that he was very confident… perhaps to the point of arrogance… but so what. He was certainly enthusiastic. He had completed 100 cave dives in a couple of years, and when you live a 16-20 hour drive from the caves, 100 dives is enthusiasm in bold letters. But, in truth, he really had not been diving long, and he certainly did not have vast experience regardless of his many postings on onLine forums and Facebook, and even though he had ticked off several “big” dives in his logbook. However, I do not believe any of that had anything to do with him being dead right now.

Experience whispers strange things in our ear. I have lost many, many friends to diving, and have seen many people who I did not know personally… like Carlos Fonseca… die in the water. Part of the work I choose to do involves picking through the debris folks like Carlos leave behind. The task is to identify what went wrong and make sure others understand the circumstances surrounding the incident, the events that triggered an incorrect reaction perhaps, so that nobody makes the same bloody error. Sometimes this is difficult, but not in this case. There is no doubt about what happened; no question what triggered the victim’s death or whose actions contributed to that death. Of course, the resulting analysis may be difficult for some to accept.

A buddy of mine is a lawyer who specializes in cases where some poor bastard has died, and he tells me his staff have a kind of open pool going to see how long it is before a friend or relative says, writes or posts on the internet something along the lines: “He was the best diver in the world… I simply do not understand how a thing like this could happen…”

Someone always says that, even when the diver is a total novice… just like that kid who died in California a couple of years back trying to do an air dive to 80 metres. He was a divemaster… maybe, I forget. Anyhow, he had ZERO training to do that sort of dive but the boy’s father insisted his son was a “professional” and would not accept evidence to the contrary… or that his son had probably been lulled into complacency and hubris by his slightly more experienced and certainly older dive buddies.

In the case of Carlos, we know what went wrong and we have evidence that the victim ignored warnings from his fellow divers. He certainly ignored best practice. He is not the first diver to make such a rookie mistake, and the fact that a few years ago he knew nothing at all about diving is truly irrelevant. He DID know what SHOULD have been done. He had sat through training and certainly had correctly answered exam questions on gas management. HE CHOSE TO IGNORE WHAT HE KNEW. This is not because of lack of experience or because he progressed rapidly. He simply ignored what he knew to be the right thing to do… that’s a function of character, poor judgement, pressure or stress: take your pick.

In the final assessment, Carlos Fonseca believed the rules did not apply to him. He certainly knew that the established practice is to ANALYSE and LABEL every cylinder that goes into the water.

Is there something to learn from this incident? Of course there is. It’s the title of this piece. But there is also something else I would like to remind you of just in case someone reading this has ANY doubt. YOUR BUDDY IS CARRYING YOUR CONTINGENCY GAS… IF YOU DO NOT KNOW WHAT IT IS (first-hand, having checked for yourself) THEN YOU SHOULD. YOU may need to breathe it at some point. There can be NO credible argument against this, in my opinion.

12 thoughts on “The Rules Apply to All of Us

  1. Steve, Thanks for the post. I’ll play Devil’s Advocate, not because I necessarily agree with the points that I am going to make, but because they are out there and will likely promote discussion…

    1. “OUR BUDDY IS CARRYING YOUR CONTINGENCY GAS… IF YOU DO NOT KNOW WHAT IT IS (first-hand, having checked for yourself) THEN YOU SHOULD. YOU may need to breathe it at some point. There can be NO credible argument against this, in my opinion.”

    – requires you to have a true team ethos when you go diving. Unfortunately this is lacking in a vast number of divers, especially those who were taught by instructors with a solo mentality. If no-one is going to use ‘my’ gas, why should I care about the implications of someone else using it. If he was a regular solo diver, there wouldn’t be the ‘check’ in place to make sure that he was doing procedures correctly, which would include gas analysis on every dive. I know of a Mod 1 in the UK fairly recently where no gas analysis took place for onboard or bailout cylinders…

    2. “In the case of Carlos, we know what went wrong and we have evidence that the victim ignored warnings from his fellow divers. He certainly ignored best practice. He is not the first diver to make such a rookie mistake…HE CHOSE TO IGNORE WHAT HE KNEW. This is not because of lack of experience or because he progressed rapidly. He simply ignored what he knew to be the right thing to do… that’s a function of character, poor judgement, pressure or stress: take your pick.”

    – many of us do things that we know to be wrong but do them anyway. Many of us ‘drift into failure’ because we have previously made bum decisions which have been validated by nothing going wrong. Langewiesche (http://www.theatlantic.com/magazine/archive/1998/03/the-lessons-of-valujet-592/306534/) said that “Murphy’s law is wrong: Everything that can go wrong usually goes right, and then we draw the wrong conclusion.” Something that I have pondered as I have done my research is do we limit the speed we drive when over the limit (as most people do) because we don’t want to get caught and get a significant fine, or are we considering the safety aspects, either ourselves or a pedestrian/other driver.

    – It is easy to pick a single incident and analyse it using hindsight bias, but how many dives had been made where the gas analysis hadn’t taken place and nothing went wrong. Doesn’t make it right, but it might explain why there was a reluctance to analyse the gas.

    – Finally, those who are at the higher end of diving (e.g. tech OC divers, cave divers and CCR divers) all have significant egos, some of which are more controlled than others, but we wouldn’t have the drive or dedication to get to where we are without that ego. If someone was publicly questioning a driven individual in a public place, and they think they might be wrong, then I doubt they are going to ‘back down’. That is the culture we live in. How to address this? Spend more time on instructional courses to be truly self-reflective in our failures during training classes, and not just congratulate divers for passing certain sections of the class.

    Thanks for putting the email together. I know you have a large following, so hopefully the message will gradually get out there. I have put two blog entries up recently (in the last 6 months) with the same message.

    Regards

    Gareth

  2. I recall a quote from somewhere about “There are old divers, and bold divers, BUT no old and bold divers”! I know of a few experienced dive instructors, who brag about dives up to 200 ft, and even attempting to bring tanks with different gas mixes to get to at least 250 ft!

  3. IT does not matter what happen . His family lost a father , husband ,friend etc. It does not matter who made the mistake . He’s gone ,Lets just send a prayer out there for the family and hope they can go on with their life’s somehow . It sounds like he was a great person for all. God bless his famiy and god bless all divers .[ I'm new to the sport]

    • I believe it does matter. We learn from mistakes. We learn from accidents. Diving is unforgiving of both types of events, so better to learn from those made by others.

  4. Pingback: Doppler’s Tech Diving Blog | Jump - Sail - Dive

  5. It is really important to follow rules because this also one way of ensuring our own safety. Maybe It may sound really hard for us to follow but we really need to follow these rules. As the saying goes “better be safe than sorry”.

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