Public Information on diving fatalities (LA County)

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Posted by Ken Kurtis on February 04, 2006 at 13:06:04:

I thought I'd respond separately to the thread below.

A lot of what you're asking about is public information, available through the LA County Coroner's Office (assuming the fatality occurred within their jurisdiction).

Anytime there's a fatality, an investigation is initiated by the Sheriff's Emergency Services Department, and there's a multi-part report compiled by the Department of Coroner. Part of that is a report on the state of the equipment once it's been tested and an analysis/comment on what may have caused the accident to happen.

I know this last part is true because for the last two-and-a-half years my partner Bill Wright and I have been the ones doing this work for the Coroner.

One of the things we're all trying to make happen soon is how to properly publicize these reports and make them easily accessible to the diving public. One thought is that we might be able to make them available through the Catalina Hyperbaric Chamber website. There are still some details to be worked out.

Last year at Scuba Show 2005, we presented a special panel called "Why Divers Die" where we examined and presented to those in attendance, three cases that had occurred during the previous year. The panel consisted of Coroner Chief Craig Harvey presenting the overall case, Chamber Director Karl Huggins explaining the Chamber's involvement and treatment, and myself presenting what we discovered post-accident and what conclusions we drew. We hope to do a similar panel at the Scuba Show this year.

In general, there are about 10-12 fatalities a year in LA County. A lot of times, diver errors and miscalculations come into play. We have yet to see a case where equipment failure caused an accident, although sometimes the equipment performance may have hampered the victim's ability to respond to the situation. (For instance, we've had cases where regulators breathed hard or BCs had slow leaks, etc., etc., but those factors didn't set the accident in motion.) We've had one death under suspicious circumstances, and the last three fatalities (all within a week of the opening of lobster season) have all been ruled to have medical causes.

One of the problems with public discussions of these events is that, while the discussion can definitely be valuable if people can confine themselves to examining the known facts and resist speculating and assuming, too often people have jumped to conclusions and assumed facts-not-in-evidence and just gotten things plain wrong. Some people have also been prone to finger-pointing and accused of using the accidents selectively to promote their own agenda. Unfortunately, it all just become non-productive.

Patience is virtue. Even with our investigations for the Coroner, while we usually get notification within 24 hours of an accident and receive the gear within 72 hours of the accident (and try to test it right away), we may still spend another month of so getting witness statements, getting more background on the diver's experience, and stuff like that, before we issue a report.

For instance, there was one diver who was found (by his buddy right after they got separated), entangled in the anchor line of their private boat (wrapped around the victim's leg), reg out of mouth, weight belt ditched, and 2700psi in the tank. This diver had made about 800 dives and dove regularly. The biggest question was: Why would an experienced diver with an almost-full tank of air not keep the reg in his mouth and simply wait for assistance?

Further investigation revealed to us that the air was shut off on the tank. By going back through the chain of evidence (in other words, who had handled the gear), we were convinced no one turned it off post-accident. The victim's buddies on the boat however, did not recall seeing him turn off the air after assembling his gear. However, further interviewing other dive buddies revealed that the victim regularly would turn off his air on previous dives and, if he forgot to turn it back on before sumberging, would simply reach back and open the valve. This helped estbalish a pattern of diving behavior.

We also ran in-water tests on the reg to see how deep we could get by turning the air on, then shutting the valve, and the diving down. On our test dive, we reached a depth of 47' before we got the last breath of air, and that was consistent with the depth at which the victim was found.

So our conclusion in this particular case (which we presented at our Scuba Show 2005 panel) was that the victim turned off his air, forgot to turn it back on before entering the water, got down to significant depth, ran out of air, turned to do a free ascent when he couldn't turn the air back on, got tangled up in the line, ditched his weight belt to try to free himself, remained stuck, and then passed out and drowned.

To answer our original question, he didn't put the reg back in his mouth because the reg would not deliver air and was useless to him, since the valve was closed.

But to reach this conclusion took us about two months of testing the gear, interviewing people, retesting the gear, developing a theory, testing the theory (we actually had two other scenarios that we shot down as being not realistic), and then feeling comfortable with our results.

So a lot of times this information is not so much withheld from the public but, by the time it's assembled, it's long after the accident and the public interest has waned. But one of our goals is to do a better job of making this information available because all divers can learn from it.

The overall things to walk away with are:
- It's rarely only one thing going wrong that causes an accident
- Frequently, it's one thing, then another, and eventually there's overload
- Abort dives when the first thing goes wrong
- Fix whatever went wrong (if you can - if not, you;re done), and then resume the dive
- Pay attention to your air supply
- Understand your limits and don't push them

I know it all sounds simplistic, but for almost all of the divers we've looked at, the accidents were preventable.

Enough of me on the soapbox. Hope this helps explain the situation somewhat. If you have any questions feel free to ask or e-mail me directly.

Ken Kurtis
NAUI Instr. #5936
Co-owner, Reef Seekers Dive Co.
Beverly Hills, CA

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