Incident Report

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Incident Report 2020-05-01T16:26:00+00:00

Out tag confusion

Incident Date

2005-01-07

Incident Description

Two divers (both experienced and familiar with the cave) were diving downstream from Hurtle Pot to Midge Hole. Diver A in the lead marked a line junction downstream from OYCFK airbell. On the return he arrived at the junction removed the tag and followed the line which ended after approx 2 metres. Close inspection of the line and surrounding area revealed no line beyond. The second diver (Diver B) who knew the system better than Diver A realised that Diver A had put his out tag on the wrong line and indicated the correct line. Both divers exited safely via Hurtle Pot.

Lessons Learned

To this day Diver A cannot explain his error in putting the tag on the wrong line. Vis was good and the junction is in a spacious passage. Clearly this error could have been extremely serious. Whilst Diver A made the original error it is apparent that Diver B relied on a combination of his trust in Diver A to mark the junction correctly and his knowledge of the system to get him out safely. He should have checked Diver As mark on the way in and perhaps used his own tag in addition to Diver As. If Diver A had exited before Diver B and removed his tag Diver B would have had no mark to follow. The divers had not discussed junction marking prior to the dive. Diver A would have left the tag in place for Diver B which might have caused confusion if Diver B had thought Diver A had not yet exited.
Factors
Line Management Major
Gas Management Negligible
Equipment Management Negligible
Equipment Failure Negligible
Training Negligible
Medical Negligible
Planning Minor
Procedural Error Major
Cave Environment Negligible
Weather Negligible
Other Factor Unknown