Tödlicher Tauchunfall im WKPP Team

  • Hallo,
    möglichst genaue Infos zum tödlichen Tauchunfall eines Mitgliedes der WKPP am 11.06.2011.
    Die Informationspolitik ist sehr transparent, deswegen möchte ich das gerne auch auf deutsche Listen forwarden.


    Save diving,
    Hoffi


    ++++++++++++++



    Eine rohe, inhaltliche Übersetzung des posts von Todd Leonard, Projektmanager der WKPP, mit einigen Info's zum Mensch Jim Miller aus Casey McKinleys post ( Posts anhängend )


    Falls ich was falsch wiedergebe oder ein wichtiges Detail auslasse,
    bitte unbedingt nachbessern, danke.


    +++++++



    Jim Miller,
    kürzlich zum Colonel der US Army befördert, also aktiver Armeeoffizier, WKPP-Supporttaucher seit 2002,
    Senior Team Explorer mit regelmässigen Langstrecken Tg's auch für die WKPP, er hatte z.B. gerade einen langen 12000ft / 3,7km Setup für die WKPP absolviert.
    Er galt als methodisch und detailorientiert in seiner Taucherei, hochrespektiert in seinen Kreisen und der WKPP.


    Samstag 11.06.2011,
    Jim begibt sich auf einen Tg im Dreierteam,
    Whiskey Still Sink, Teil des Wakullaparks.


    RB80 pSCR,
    max Tiefe ca 67m,
    Stages mit 6m/20ft O2,
    21m/70ft Heliox 50,
    36m/120ft
    und zwei bottomstages,
    240ft/75m Gas.


    Der Tg beginnt auf dem 36m Gas, gut passend zum initialen Höhlenprofil, ich kenne das Profil nicht aber es klingt als wär man ein Weilchen rein gefahren um dann weiter hinten die Dekogase abzulegen, 6m und 21m.
    Beim Stageablegen auf dem 21m/70ft stop passierte der erste, hochkritische Fehler,
    Jim legt versehentlich eine der bottomstages, 75m 240ft ( MODmarker 240 ) ab und behält das Heliox50, 21m Gas am Mann.


    Weder Jim noch sonstwem im Team fällt dieser erste kritische Fehler auf.


    Wer sich näher mit tieferem Techtauchen nach WKPP/GUE-Training beschäftigt weiss um die extrem sorgfältig und mit vielfachen Checks ausgestatteten Gaswechselprozeduren die in solchen Kreisen eigentlich üblich sind um besonders solche tödlichen Fehler zu vermeiden.
    Und zuvorderst ist es natürlich der Taucher selbst der einen Gaswechsel zu jedem Zeitpunkt hochwachsam durchführen sollte.
    Im weiteren Tauchgangsverlauf,
    Gaswechsel auf 120ft/36m, hier passiert der zweite hochkritische Fehler, Jim wechselt versehentlich vom 36m Gas auf das 50er Heliox / 21m Gas, eigentlich wäre das 75m/240ft Gas einzustöpseln gewesen.


    Weder Jim noch ein anderes Teammitglied fällt dieser genickbrechende Gaswechselfehler auf.


    Das Team beginnt die Grundzeit, nach etwas weniger als einer Stunde gehts wieder zurück wie geplant.
    Kurz nach der Wende krampft Jim in offensichtlich schwerer O2-Vegiftung und ertrinkt, die Hilfsversuche seiner Buddies sind vergeblich.
    Das Team bringt Jim Miller im selben TG mit raus, tot.



    Übersetzung: Jan Hinrich Hoffmann


    ( crossposts mit Genehmigung vom Caverdiver's net
    und anderen Listen )


    +++++++


    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


    +++++++


    Re: Fatality in the WKP - 6/11/11
    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




    +++++++++++++++




    Todd
    Thanks for taking time to follow up on many of the questions. Those of you close to Jim can email Todd directly for information regarding the services scheduled for this Saturday in Orlando. I am not sure of all the forums carrying this topic so please cross post where appropriate.


    To the best of my knowledge:
    Avg depth from WSS through Ashee to Innisfree is shallow – I believe 40-60ft max. Deco must start downstream of Innisfree as the sink comes shallow before heading back upstream to WSS


    Jim was mostly in the lead (in and out) following the final switch


    It appears Jim was the last diver to leave the 70ft drop where the first error was made in dropping the wrong (240) tank


    There is most certainly NOT a culture of complacency within the team. The WKPP would not exist today if that were the case. You can bet that procedures will be re-emphasized but even the most robust procedures do not work without a commitment on behalf of the diver and the dive team. If there is a better way to do it we will seriously evaluate that possibility.


    All of Jim’s tanks were marked correctly with MOD, each tank had current analysis on it and we have every reason to believe the analysis was accurate but this cannot be verified because the equipment was impounded and the mixes are being confirmed by the authorities. I have no reason to believe they would be different than indicated by the tape.


    Forrest’s comments are spot on. Without Jim we will never know what may have been distracting him from his normal attention to detail during gas switch procedures. Bad things happen to good people and we will be reminded of that reality for a long time. Procedures are in place but they must be followed. Secondary checks must also be followed but the diver has a primary responsibility to himself and his team. This is serious business and I am sure most technical divers understand this. The tragedy is that it takes the loss of a competent, capable and experienced diver not to mention a friend, son, veteran and outstanding member of the community to remind everyone of the basics. There are no excuses.


    I would also like to note that on behalf of the WKPP there has never been an official or unofficial policy to withhold information regarding any incident from the diving community. The WKPP works tirelessly to remove as much risk as possible from these endeavors but we would be kidding ourselves to pretend there was little or no risk in exploration. Explorers must be permitted to explore, procedures must be followed and preparations must be in place to deal with both good and bad situations. The response will make all the difference since it is never a matter of “if” and only a matter of “when”. I recognize the WKPP for numerous reasons has never been popular with many segments of the diving community. I do not expect to be able to change that but I personally assure you that any information, accident analysis or details learned will always be made public in as timely a manner as possible. The entire community takes a hit regardless of the dive site or the dive team and making a post accident phone call to the family is something no one should ever have to do in their lifetime.


    Respectfully,


    Casey McKinlay
    Project Director
    Woodville Karst Plain Project

  • Hai Hoffi,


    danke dir für die Übersetzung. Ich bin sehr erschüttert über diesen Unfall. Es führt einen wieder vor Augen, dass jeder Tauchgang, und habe ich ihn noch so oft gemacht, immer Gefahren birgt.
    Ich beobachte es häufig, auch an mir selber, dass gerade bei Tauchgänge, die regelmäßig durchgeführt werden, die Aufmerksamkeit nachlässt. Dies ist im technischen Tauchen und gerade auch im Umgang mit Rebreathern ein fatales Verhalten.


    Jeder sollte versuchen, bei jedem Tauchgang ein hohes Maß an Aufmerksamkeit zu haben. Ich arbeite auch daran.


    Viele Grüße


    Volker

  • Moin!



    Was mich betrifft, so frage ich mich, ob es eine Sauerstoffüberwachung am RB gab. Die allgemeine GUE Meinung iss ja, es kann darauf verzichtet werden weil die RB`s ja völlig mechanisch arbeiten und kontrollierbar sind...


    Ich war allerdings froh das ich mal eine hatte/ habe!


    Evetl. hätte hier eine PPO2 Überwachung nach allen vorherigen Fehlern das schlimmste dennoch verhindert!


    Ich verzichte jedenfalls nicht darauf obwohl ich auch eine PSCR tauche und die Möhre gut kenne!


    Gruß, Kuddel.

  • Hallo zusammen,


    ich bin ja aufgrund fehlender Zeit nicht mehr häufig hier anzutreffen, meine mich aber erinnern zu können, dass Tauchunfälle oder Berichte hier im Forum nicht geduldet werden.


    Tauchunfall beim Eistauchen


    Schönen Gruss
    Markus

    Ich kann garnicht tauchen. Mein karges Wissen habe ich aus anderen Foren. Ich rede hier nur schlau mit und versuche Frauen kennenzulernen.
    Wenn ich in Safaga tauche, werde nicht ich nass - Das Rote Meer wird Markus.
    Zwei Tage nach meinem OWD war Arielle nur noch Meerfrau.

    Edited once, last by Markus ().

  • Quote

    Original von Markus
    ... Tauchunfälle oder Berichte hier im Forum nicht geduldet werden.


    Hierbei handelt es sich um eine seltene Ausnahme, da dieser Fall lehrreich für andere ist und es in diesem Bericht weder Spielraum für Spekulationen über den Hergang des Unfalls noch zur Ursache gibt.

  • Quote

    Original von Kuddel
    Was mich betrifft, so frage ich mich, ob es eine Sauerstoffüberwachung am RB gab..



    Das war auf allen internationalen Foren auch Thema,
    nein,
    es wurde keine aktive PO2 Messung, benutzt.


    Casey McKinley geht da auch in einem post drauf ein...


    Quote


    Casey McKinley:
    A PO2 meter might have been useful (if he looked at it), a setup team to place the deco gas might have been useful, placing the deco gas first and then returning to start the dive might have been useful, having a setup team follow the dive team with deco gas might have been useful, no deco gas might have been useful and likely another 100 different combinations of the above might have been useful. But in the end, checking the MOD on the tank your breathing is the procedure and should apply on a single tank and multi tank dive.I would have planned the dive the same way and will do the dive the same way, with all MOD checks, next Tuesday when we dive to retrieve some of the equipment that was left behind.



    Gruss,
    Hoffi

  • Hallo,


    gibt es einen Bericht der der beiden Tauchpartner? Äußerungen warum oder wie der Fehler beim Stagehandling passieren konnte?



    @ Taucher Tom


    wo findet man diesen "Original-Thread"? Ist ein ein frei zugängliches Forum? Wenn ja, kannst Du diesen verlinken?


    Gruss

    German quarry pond diver :taucher:


    ***Die Natur ergreift immer die Partei des versteckten Fehlers.***

    Edited once, last by mike.h ().

  • Quote

    Original von mike.h
    Hallo,


    gibt es einen Bericht der der beiden Tauchpartner? Äußerungen warum oder wie der Fehler beim Stagehandling passieren konnte?


    Nicht dass mir da was bekannt wäre.
    Mir wär nicht nach dem Schreiben von Berichten wenn mir vor 10 Tagen ein Freund und Tauchpartner unter meinen Augen weggestorben wäre.



    Quote

    Original von mike.h


    Wo findet man diesen "Original-Thread"? Ist ein ein frei zugängliches Forum? Wenn ja, kannst Du diesen verlinken?


    Gruss


    Es gibt eigentlich auf jedem englischsprachigen Board einen Thread.
    UU ist der Thread auf CaverdiverNet gemeint, da approved der Admin neue Mitglieder allerdings manuell, kann ein bisschen dauern.


    http://www.cavediver.net/forum…11-11?p=149984#post149984



    Gruss,
    Hoffi