Diver Duties

Sample Accident Report

Date: 4 April 1997
Time: 1200 EDT
Location: Grays Reef Marine Sanctuary, Savannah, Georgia
Dive site: Small Boat from NOAAS FERREL on Grays Reef
Emergency Chamber: Memorial Medical Center, Savannah, Georgia
Dive Team: [Victim Name], [Buddy #1] and [Buddy #2]

The profile of the dive and chronology of events was as follows:

On April 9, 1997 (Wednesday) [Victim Name], [Buddy #1] and [Buddy #2] completed a dive in the Gray’s Reef marine sanctuary. The purpose of the dive was to capture a sea turtle on the reef and transport the animal to FERREL for attachment of a radio transmitter. Dive equipment was standard open circuit SCUBA as issued from the Standardized Equipment Program. Breathing media was air. Proper pre and post dive protocol was followed and the dive was completed without incident. The dive profile was as follows:

Depth	Surface to Surface Time
65 fsw	17 minutes

Surface weather conditions were clear and sunny, temperature 74° F, wind SE @ 8kts, seas 1-2ft. Water temperature was 70° F, underwater visibility was 20-30ft and there was a 3/4 to 1kt bottom current. The dive plan was to descend to the reef on a down line, locate a turtle, capture it with a net and return to the surface. When the divers reached the bottom, the down line had been swept off the reef. The anchor had left a trail in the bottom in the direction of the reef so the dive team began swimming towards the reef, against the current. [Buddy #2] was carrying the turtle net and [Victim Name] was carrying the down line that had a ten-pound anchor. It took the divers approximately five minutes to reach the reef. Once on the reef, the divers rested for two minutes then began searching for a suitable turtle. Within four minutes the dive team located a turtle and attempted capture. [Victim Name] and [Buddy #1] struggled with the turtle for approximately three minutes while [Buddy #2] positioned the net and completed the capture. The team then ascended up the down line with the turtle and returned to the ship. During the post dive briefing, the dive team discussed the difficult swim against the current at the beginning of the dive. [Victim Name] stated that, " Once I reached the reef, I was out of breath and could feel my heart pounding." The dive team members all indicated that they felt fine, stowed equipment and continued normal work routines for the remainder of the day.

The afternoon of April 10, (Thursday), [Victim Name] informed [Buddy #2] that he was very tired and complained of a headache. [Buddy #2] examined him for additional signs and symptoms of DCS and found none. [Victim Name] took the remainder of the afternoon off and returned to bed. On the morning of April 11, (Friday), [Victim Name] informed [Buddy #2] that he "Felt bad." [Buddy #2] noticed that he was moving and speaking slower than usual and performed a neurological examination that showed loss of coordination in [Victim Name] legs as well as reduced mental functions. [Victim Name] was given 100% oxygen and transported to the hyperbaric facility at Memorial Medical Center in Savannah, Georgia. He was examined by Dr. Ed Grimsley at the medical center, who diagnosed type II decompression sickness. At approximately 11:30, [Victim Name] was recompressed and treated on an U.S. Navy Table 6. At approximately 19:00 the treatment was concluded, [Victim Name] was asymptomatic and returned to the ship.

Analysis and Recommendation

[Victim Name] is an active diver and was treated for non-deserved type II DCS in 1995 following a dive to a similar depth. Since his last case of DCS, he has completed seventy-six (76) dives without incident. Prior to the current incident [Victim Name] was well rested and in good health. His last dive was five days earlier and was completed without incident. During the dive [Victim Name] was swimming against a 3/4 to 1kt current, pulling a surface float and carrying a down line with a ten-pound anchor. This additional effort, along with the work involved with struggling with a large sea turtle, caused him to overexert himself during the dive and may have contributed to his DCS.

UN-deserved decompression sickness can neither be prevented nor anticipated. Dive supervisors must continually monitor their divers, especially when DSC is suspect. The Divemaster should have done a more complete examination of [Victim Name] the day after the dive. The hospital records indicate that [Victim Name] was experiencing several symptoms of DCS throughout that day. The fact that he was extremely fatigued and suffering from a headache that morning was sufficient reason to seek medical advice. Add to this that the ship was inport during the two days following the dive and that medical facilities were locally available, makes this a major oversight.

[Victim Name] dive history, medical status and physical condition should be reviewed and evaluated to determine if his diving activity should be modified.