Incident Report

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

Fatality

Incident Date

2012-11-04

Incident Description

Lessons Learned

Diver C and/or B should have arranged to leave a marker on the line to indicate to the other that they had exited safely and that it was OK to remove the line. In any case of doubt the line should have been left in place. Diver B removed the line in good faith as every bit of evidence available suggested that C was already safe. The Coroners Inquest concluded that Diver C became disoriented - this would lead to lost line or (ignoring well-marked permanent exit arrows on two separate junctions) being on wrong line. Attempts by Diver C to deploy a search reel for exit safely and the resulting entanglement demonstrates the care with which such emergency spools should be handled especially as they are liable to be used in stressful situations.
Factors
Line Management Major
Gas Management Negligible
Equipment Management Negligible
Equipment Failure Negligible
Training Minor
Medical Unknown
Planning Negligible
Procedural Error Major
Cave Environment Minor
Weather Negligible
Other Factor